Routine inspection·May 27, 2025

At approximately 12:10 p.m. on 05/27/25, 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 04/09/2024 for an annual inspection. It is a gated, single story building with seven (07) bedrooms and eight (08) bathrooms, kitchen, common areas, 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 two (02) residents relaxing in the shaded patio area with family. Once inside, postings were observed for confidential complaint contacts, ombudsman contacts, facility license, administrator certificates, facility sketch with evacuation routes clearly labelled, emergency disaster plan, personal rights, rights of resident councils, and neighborhood complaint procedures. A screening station containing a digital thermometer, hand sanitizer, masks, and a visitor log was located at the main entrance. Walls, floors, windows, screens, and blinds were clean and in good repair. At 12:20 p.m. LPA measured the room temperature to be 74 degrees Fahrenheit. Common areas contained a piano, a karaoke machine, other musical equipment, reading materials, furniture in good repair, and exercise equipment. A fireplace was turned off and grated. The facility had seven (07) bedrooms in total. One (01) bedroom is designated as a staff room. The staff room was unlocked and free of hazards. All resident bedrooms were private. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. All exit doors were unlocked with auditory alarms on and functioning. All hospital beds had wheels in the locked positions. The facility had eight (08) 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 12:35 p.m. LPA measured the water temperature in the private bathroom to Bedroom #6 be 108.0 degrees Fahrenheit. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen and pantry. Emergency supplies of food were observed in the pantry. Appliances were in good condition. Sharps were locked in drawers. Cleaning solutions were locked below the sink. Medications and a complete first aid kit were locked above the counter tops. A washing machine and dryer were located near the dining room. Both were in working order. Detergents were locked in a storage shed outside. Three (03) covered patio areas were located in the front and side of the facility. The patios contained furniture in good condition and a gas grill. Gardened areas were maintained. The property was appropriately fenced and separated from the adjacent properties. Two (02) out of two (02) emergency exit paths were free from obstructions. Fire sprinklers were observed throughout the home. At approximately 1:00 p.m. LPA observed a fully charged fire extinguisher in the hallway. It was last inspected on 04/21/2025. At approximately 1:15 p.m. smoke and carbon monoxide detectors were tested and operational. At 1:30 p.m. the house telephone was called and deemed operational. LPA conducted a record review of resident and personnel files. All files were complete and available for audit. 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.