Facility Overview: The facility was a one story building with 10 rooms and 3 bathrooms. 5 rooms were for gym, art, isolation, game and computers. The rest were for staff offices, dining and conference room. There were no pools or known firearms on the premises.

Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements.

Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. There is no outdoor activity area. Sharp and dangerous objects were securely locked and inaccessible to residents. Both the smoke detector and carbon monoxide detector were operational, and the hot water temperature was 109°F. Fire extinguishers located at hallways had current inspection tags.

Food Service: The facility’s kitchen and dining room were observed to be clean and organized. The facility did not offer food services for the clients. LPA observed several clients having their own lunch in the dining area.

Continued on LIC809-C....

Record Review and Resident/Staff Files: LPA reviewed files for 5 staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. 5 resident files were reviewed and contained all required documentation.

Health-Related Services/Incidental Medical Services: This facility did not provide assistance with medication to any clients. This facility did not store any medication for the clients.

Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 10-17-2024, which met department requirements. All facility exits were clear of obstructions.

No deficiencies were cited during the visit. An exit interview was conducted, and this report was reviewed and provided to Norshay Easter, Program Director.