Routine inspection·July 22, 2025

At approximately 8:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with Front Desk manager Valli Lunsford and explained the purpose of the visit. Administrator certificate is current. LPA requested Licensee submit documentation to appoint an Administrator. Facility has a Hospice waiver for 11 residents. At approximately 8:30AM, LPA toured the facility to ensure the health and safety of residents in care. The facility was observed to be at a comfortable temperature. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and outdoor areas. In the areas toured no immediate health, safety, or personal rights violations were observed. Fire extinguishers were fully charged. Smoke detectors are all operational. Carbon Monoxide Detector was present. Facility has a fire sprinkler system. The common areas, bathrooms and kitchen were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. The kitchen equipment was clean and in good repair. Dishware appeared to be stored in a sanitary manner. Food appears to be stored and prepared properly. Refrigerators and freezers were maintained at the proper temperature. Facility has required seven-day non-perishable and two-day perishable supply of food. Emergency food stores and water was present to ensure facility can be self-sufficient for 72 hours. Facility has a generator to supply power in an emergency. Emergency lighting devices were present. Evacuation chairs were located at each stairwell. First aid kit was present. All employees requiring background checks are cleared. No pools/bodies of water are on the premises. Facility has been conducting Emergency drills every 3 months. Activity calendar was posted in the lobby with many activities scheduled for the day. At approximately 9:30AM, LPA reviewed 10 resident files. All resident files contained the required documentation. Reappraisals were conducted within the last 12 months. Documentation of a physician visit within the last 12 months was present. LPA conducted a review of medications. Medication is locked and not accessible. Continued on LIC809-C… At approximately 10:45AM, LPA reviewed 7 staff files. Staff files reviewed contained evidence of completed annual training and all required documents. First Aid/CPR certification was current. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report Evidence of Liability Insurance No deficiencies were observed in the areas inspected, No citations were issued during today’s visit.