Routine inspection·December 30, 2025

At approximately 8:45 a.m. on 12/30/25, 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. A file review was conducted prior to today’s visit. The facility was last visited on 11/26/24 for a complaint visit. It is a single story building with five (05) bedrooms, three (03) bathrooms, kitchen, laundry room, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which five (05) may be bedridden. Approved hospice waivers for five (05). LPA observed a maintained front yard. Postings at the front and in the hallway included COVID precautions, facility license, confidential complaints contacts, ombudsman contacts, emergency disaster plan, rights of resident councils, personal rights, and the facility sketch. Walls, floors, windows, screens, and blinds were clean and in good repair. At 8:55 a.m. LPA measured the room temperature to be 76 degrees Fahrenheit. Two (02) residents were observed in the dining room watching television. Two (02) staff members were observed cleaning and preparing lunch. The living room contained a television, reading material, exercise equipment, and furniture in good repair. A fireplace was appropriately covered and turned off. Medications were locked near the main entrance and under the counter. The facility has five (05) bedrooms. One (01) bedroom is designated as a staff room. The staff room was unlocked and free of hazards. All bedrooms contained a chair, lamp, nightstand, storage, bell or call system, and a bed with adequate bedding. All furnishings were clean and in good condition. All rooms had hospital beds with wheels in the locked position. The facility has three (03) bathrooms. Two (02) bathrooms are private to Bedrooms #3 and #4, and one (01) is shared. All bathrooms contained liquid soap, paper towels, trash can with a tight fitting lid, grab bars near the toilet and shower, commodes, and a non-skid mat in the shower. At approximately 9:30 a.m. LPAs measured the water temperature in the shared bathroom to be 106.2 degrees Fahrenheit. Interview with Staff #1 (S1) at 9:35 a.m. today revealed chemicals were stored below the sink, but the lock recently broke, so all chemicals are stored near the laundry area. LPA heard the house telephone ring at 9:40 a.m. The phone was deemed operational. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. Appliances were in good condition. Sharps were locked under the counter. The stove surface and hood were clean. A washing machine and dryer were located in the laundry area. Both were in working order. Detergents and cleaning supplies were locked near the appliances. LPA observed a shaded patio area in the rear of the facility. The patio contained furniture in good condition. A fence on the southeast side of the facility was falling into the neighbor’s yard. Interview with the licensee at approximately 11:00 a.m. revealed the neighbor next door is new and is responsible for fixing the fence. The licensee has a plan to restore the fence properly. All emergency exit paths were free from obstructions. Two (02) out of two (02) exit gates were unlocked. Four (04) out of four (04) auditory alarms were turned on and functioning. Fire sprinklers were located throughout the facility. At 11:30 a.m., smoke and carbon monoxide detectors were tested and operational. At approximately 11:35 p.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last tested on 05/16/2024 with a tag attached. At approximately 11:00 a.m. LPA reviewed staff and resident 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 or safety hazards were observed. Exit interview conducted. Copy of report provided.