Routine inspection·July 15, 2025

At approximately 12:15 p.m. on 07/15/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the licensee and disclosed the reason for the visit. The facility was last visited on 05/28/24 for an annual visit. It is a single story building with four (04) bedrooms, two (02) bathrooms, kitchen, common areas, pool, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents. Approved hospice waiver for one (01). The front gate was unlocked, and the front yard was well maintained. There was a shaded seating area under the front porch with furniture in good condition and exercise equipment. A screening station at the front contained a visitor log, digital thermometer, hand sanitizer, and test kits. Walls, floors, ceilings, windows, and screens were clean and in good repair. At 12:30 p.m. LPA measured the room temperature to be 73 degrees Fahrenheit. Postings at the front and in the kitchen included Ombudsman contacts, confidential complaint contacts, facility license, administrator certificate, rights of resident councils, emergency disaster plan, a blank copy of an admission agreement, and resident rights. The living room contained furniture in good repair, reading material, an office space, and an appropriately covered fireplace. LPA observed an adequate supply of perishable and non-perishable food in the kitchen and pantry. All surfaces were clean. The stove hood was sanitary and newly remodeled. Sharp objects were locked under a dining room counter. Cleaning solutions were locked under the sink. Medications were locked above a pantry. At approximately 12:45 p.m. LPA observed a fully charged fire extinguisher in the kitchen. It was purchased on 01/16/25 and had a receipt attached. A locked storage closet near the main entrance contained cleaning supplies. A laundry area located near the kitchen contained a washer and dryer in good condition. LPA also observed a fully-stocked first aid kit by the appliances. The facility had four (04) bedrooms. Two (02) bedrooms are designated for staff. Both staff rooms were free of hazards and clean. Bedroom #3 was private and Bedroom #2 was shared. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. All emergency exits were unlocked and free of obstructions. Two (02) out of two (02) auditory alarms on resident bedroom exits were on and operational. Two (02) out of two (02) auditory alarms at the front and rear exits were also on and operational. The facility had two (02) bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction signs, trash cans with tight fitting lids, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 1:00 p.m. LPA measured the water temperature in the large bathroom to be 107.2 degrees Fahrenheit. The back yard was well maintained. A storage shed was locked and contained gardening tools. The pool was fenced and the gate was locked with a padlock. A covered seating area was located by the pool. Furniture was in good condition. All emergency exit paths were free from obstructions. Two (02) out of two (02) exit gates were unlocked. At 1:30 p.m. LPA tested the carbon monoxide and smoke detector to be operational. At approximately 1:40 p.m. LPA reviewed resident and personnel files. All files were complete and available for audit. During today's inspection, the facility is in compliance with Title 22 regulations. No immediate health or safety hazards were observed during today’s inspection. Exit interview conducted. Copy of report provided.