According to the facility’s license, the facility has a maximum capacity of six (6) clients, all of whom must be ambulatory. During today’s inspection, there was a total of two (2) clients in care, four (4) clients are out in the community. This facility does not feature a secured perimeter or delayed egress doors.

LPA, accompanied by Administrator, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was 76 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 115.1 F, Bathroom #1 sink was 114 F, and Bathroom #2 sink was 116.6 F.

Refrigerator temperature was 38 F and freezer temperature was 0 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

No pools or bodies of water were observed on the premises. Per Administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher was serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and clients present. The interviews did not raise any significant licensing concerns. LPA reviewed multiple staff and client records/files. The reviewed files contained required documents. Confidential records were stored in locked areas. Administrator presented proof of current/active business liability insurance and surety bond.

No deficiencies were observed or cited during today's annual inspection.

An exit interview was conducted with the Administrator, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.