Facility Evaluation Report

An unannounced Annual visit conducted on the date & times indicated above by Licensing Program Analyst (LPA) K. McClurg. LPA was greeted at door by Direct Support Professional (DSP) Jaylyn Johnson. DSP contacted Administrator (Admin) Tammy Isam by phone. LPA stated purpose of visit & Admin stated that they would be there shortly LPA did state that cabinet in office containing medications was observed to be unlocked. Admin joined LPA later in visit.

LPA confirmed with DSP that they were the only staff working when LPA arrived. Upon entrance to facility LPA observed in office a with cabinet inside with doors open. Keys observed to be in lock of open cabinet. LPA observed that open cabinet contained resident medications as well as facility knives. Cabinet also contained a cleanser. Desk in office had locked box on it observed to be unlocked containing keys to medication storage in laundry room, facility van, & normally includes key to medication cabinet in office according to Admin. Screwdriver observed in top middle drawer of office desk in front of window.

Upon Admin arrival, LPA shared photos of open cabinet with hazardous contents, as well as lock box unlocked on desk in front of window, & screwdriver in drawer in desk under window. Admin could observe that cabinet in office was unlocked & that there was a screwdriver accessible in desk. Admin removed screwdriver, locked medication cabinet in office, & put keys in lockbox & locked the box @ time of visit.

This visit to be continued at a later date.

Exit interview conducted with Admin. Report provided.