State of Michigan DEPARTMENT OF HUMAN SERVICES December

State of Michigan
DEPARTMENT OF HUMAN SERVICES
BUREAU OF CHILDREN AND ADULT LICENSING
RICK SNYDER
MAURA D. CORRIGAN
GOVERNOR
DIRECTOR
December 17, 2014
Ime & Raphael Etuk
908 College Ave. NE
Grand Rapids, MI 49503
RE: License #: AF410306794
Victory Palace
908 College Ave. NE
Grand Rapids, MI 49503
Dear Ime & Raphael Etuk:
Attached is the Licensing Study Report for the above referenced facility. The study has
determined substantial compliance with applicable licensing statutes and rules. Your
license and special certification are renewed. They are valid only at your present
address and are nontransferable.
Please contact me with any questions. In the event that I am not available and you
need to speak to someone immediately, you may contact the local office at (616) 3560100.
Sincerely,
Ian Tschirhart, Licensing Consultant
Bureau of Children and Adult Licensing
Unit 13, 7th Floor
350 Ottawa, N.W.
Grand Rapids, MI 49503
(616) 644-9526
MICHIGAN DEPARTMENT OF HUMAN SERVICES
BUREAU OF CHILDREN AND ADULT LICENSING
RENEWAL INSPECTION REPORT
I.
IDENTIFYING INFORMATION
License #:
AF410306794
Licensee Name:
Ime & Raphael Etuk
Licensee Address:
908 College Ave. NE
Grand Rapids, MI 49503
Licensee Telephone #:
(616) 432-9493
Licensee Designee:
N/A
Administrator:
N/A
Name of Facility:
Victory Palace
Facility Address:
908 College Ave. NE
Grand Rapids, MI 49503
Facility Telephone #:
(616) 432-9786
Original Issuance Date:
06/21/2010
Capacity:
4
Program Type:
MENTALLY ILL
DEVELOPMENTALLY DISABLED
AGED
TRAUMATICALLY BRAIN INJURED
Certified Programs:
DEVELOPMENTALLY DISABLED
MENTALLY ILL
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II. METHODS OF INSPECTION
Date of On-site Inspection(s):
12/15/2014
Date of Fire Inspection:
12/15/2014
Date of Environmental/Health Inspection:
12/15/2014
At the time of the inspection:
No. of staff on duty
No. of residents present
# Interviewed
and/or Observed
3
3
3
3
Additional Information:
• Guardian/case manager/family member interviewed? Yes
If no, explain. Not necessary.
• Medication pass / simulated pass observed? Yes
No
•
•
•
•
No
If no, explain.
Resident funds and associated documents reviewed for at least one resident?
Yes
No
If no, explain.
Meal preparation / service observed? Yes
No
If no, explain.
Not mealtime.
Fire drills reviewed? Yes
No
If no, explain.
E-scores reviewed? (Special Certification Only) Yes
If no, explain.
No
N/A
III. DESCRIPTION OF FINDINGS & CONCLUSIONS
This renewal inspection involved a review of all applicable key indicators as noted on
Key Indicator Reference Sheets. The renewal inspection included follow-up on
corrective action plans and rules cited at the last renewal inspection and any special
investigations since the last renewal. Exclusionary notices and incident reports since
the last renewal inspection were also reviewed. Verification of rule compliance
included direct observations of the physical environment and the program, interviews
with staff and residents, and a review of the facility’s applicable records.
The facility is in compliance with all applicable rules and statutes.
Licensee was informed that, pursuant to MCL 400.713(3)(e), they are responsible for
assessing the good moral character of any person who provides care for residents of
this facility under the direction, or in the place of, the licensee.
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The licensee, at the time of this renewal inspection, was found to be in compliance
with those rules related to the handling and accounting of resident funds and
valuables. This determination is based on the financial information provided by the
licensee for those resident files reviewed.
IV. RECOMMENDATION
I recommend issuance of a regular license and special certification to this AFC adult
family home (capacity 1-4).
December 17, 2014
_________________________________________
Ian Tschirhart
Date
Licensing Consultant
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