Facility Evaluation Report

Licensing Program Analyst Shawna Doucette (LPA) arrived at the facility unannounced to conduct a Required Annual inspection. LPA was granted entry into the facility by Staff Neptallie Sanlitan. LPA met with Staff Avelina Santlitan. Administrator gave permission for Staff to assist with the visit and sign for this report.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Kitchen toured, appeared clean and safe for food preparation. Food supply checked, LPA observed an adequate supply of food. Resident rooms checked. Hot water measured at 111.4 degrees F. Facility was set at 75 F.

Fire extinguisher serviced on 12/17/2024. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted 03/12/2025. All cleaning supplies are locked in a closet. Medications were locked in a cabinet.

Facility has a pool which is locked inside a fence inaccessible to clients in care. Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching.

LPA reviewed staff and client files. Medications were reviewed. Centrally stored log was complete.

An exit interview was conducted with the Administrator and a copy of this report was provided.