Routine inspection·October 9, 2025

At approximately 8:50 a.m. on 10/09/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and disclosed the reason for the visit. The facility was last visited on 08/23/24 for an annual inspection. It is a single story building with seven (07) bedrooms, three (03) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents. The facility serves residents with dementia. Approved hospice waivers for six (06). Surveillance cameras are located in common and exterior areas. The front driveway was gated and unlocked. Shaded seating was available at the front along with gardened areas. A ramp which led up to the front entrance was in good condition. Inside the main entrance, LPA observed postings for facility sketch, administrator certificate, a blank copy of the admission agreement, emergency disaster plan, rights of resident councils, personal rights, COVID precautions, confidential complaint contacts, and ombudsman contacts. A screening station contained a visitor log and hand sanitizer. Walls, floors, windows, screens, and blinds were clean and in good repair. At 9:00 a.m. LPA measured the room temperature to be 72 degrees Fahrenheit. A resident was observed in the living room watching television. The living room also contained furniture in good condition, board games, reading materials, and exercise equipment. Night lights were present in hallways. Two (02) hallway closets contained adequate supplies of fresh linens and hygiene supplies. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen and the garage. The stove and the hood were clean. Appliances were in good condition. Sharps were locked below the counter top. Cleaning solutions were locked in the laundry area and in a locked chest outside. Medications and confidential files were locked in the office area. At approximately 9:20 a.m., LPA and staff conducted a medication review. All medications were maintained in the proper quantities. A washing machine and dryer were located near the kitchen. Both were in working order. At 9:35 a.m. LPA observed three (03) fully charged fire extinguishers throughout the home. All were last inspected on 06/04/25 with tags attached. The facility has seven (07) bedrooms. One (01) bedroom is designated as a staff room. The staff room was free of hazards. All 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 in the locked position. The facility has three (03) bathrooms. One (01) bathroom is private and two (02) are shared. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, 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 9:45 a.m. LPA measured the water temperature in the front, shared bathroom to be 118.8 degrees Fahrenheit. LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition. The back yard was maintained and contained gardened areas and a locked storage shed. Two (02) out of two (02) emergency exit paths were free from obstructions. Exit gates were unlocked with self-closing latches. At approximately 9:50 a.m., smoke and carbon monoxide detectors were tested and operational. At 9:55 a.m. the house telephone was called and deemed functional. The garage was accessible and contained extra supplies and perishable food. At 10:15 a.m. LPA conducted a records review of resident and personnel files. All files were complete and available for audit. No immediate health and safety risks were observed during today’s visit. Exit interview conducted. Copy of report provided.