Routine inspection·May 27, 2025

At approximately 8:45 a.m. on 05/27/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the licensee and disclosed the reason for the visit. The facility was last visited on 04/09/24 for an annual inspection. It is a gated, single-story building with five (05) bedrooms and four (04) bathrooms in the main building. There is also a detached guest house with one (01) bedroom and one (01) bathroom. Also present were a kitchen, common areas, tennis court, swimming pool, and outdoor areas. It has an approved fire clearance for six (06) bedridden residents. The facility serves residents with dementia. Approved hospice waivers for six (06). At the main entrance, LPA observed postings for confidential complaint contacts, ombudsman contacts, facility license, administrator certificates, facility sketch, emergency disaster plan, personal rights, rights of resident councils, and neighborhood complaint procedures. A screening station containing a digital thermometer, gloves, masks, and a visitor log was located at the main entrance. Walls, floors, windows, screens, and blinds were clean and in good repair. At 9:00 a.m. LPA measured the room temperature to be 74.3 degrees Fahrenheit. Reading materials, board games, and exercise equipment were available. LPA reviewed resident and personnel files at 9:15 a.m. All files were available for audit and complete. The facility has six (06) bedrooms in total. One (01) bedroom is designated as a staff room. The staff room was locked and free of hazards. All resident bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. All beds with wheels were maintained in the locked position. The facility has five (05) bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 10:50 a.m. LPA measured the water temperature in the shared bathroom to be 115.6 degrees Fahrenheit. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen and pantry. The stove hood was clean. Appliances were in good condition. Sharps were locked below the counter. Cleaning solutions were locked below the sink. Medications were locked near the kitchen. The medication cabinet had med lists posted. The most recent physician orders were labelled and dated. A washing machine and dryer were located outside near the tennis court. Both were in working order. Detergents were locked in a nearby storage shed. Two (02) other storage sheds containing extra supplies, tools, and cleaners were locked. The tennis court was free of hazards. The swimming pool was gated, locked, and inaccessible. Covered and uncovered patio areas were located in the front of the facility. The patio contained furniture in good condition. Two (02) out of two (02) emergency exit paths were free from obstructions, and both exit gates were unlocked with self-closing latches. Five (05) out of five (05) auditory alarms were turned on and functioning. At approximately 11:00 a.m. smoke and carbon monoxide detectors were tested and operational. At approximately 11:10 a.m. LPA observed a fully charged fire extinguisher in the hallway. It was last inspected on 04/01/2025. At 11:15 a.m. the house telephone was called and operational. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed. Exit interview conducted. Copy of report provided.