Routine inspection·April 29, 2025

At 10:00am, Licensing Program Analyst (LPA) Angela Panushkina arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA met with the Staff #1, who granted access to the facility. Administrator arrived shortly after, and LPA explained the reason for the visit. At 10:10am LPA conducted a physical plant tour and observed the following: Facility is licensed for capacity of six (6) Non-Ambulatory of which one (1) may be Bedridden. Hospice waiver for four (4) residents is also approved. LPA observed there to be sufficient stock of one-week perishable foods and two-day non-perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. All knives were observed to be locked in the kitchen drawer. Medications were kept in the kitchen cabinet and observed to be locked and inaccessible to residents in care. There is a complete first-aid kit in the cabinet with all required supplies and with the first aid manual. The fire extinguisher is located in the kitchen area and was last serviced on 02/18/2025. Laundry is located by the kitchen, and LPA observed all chemicals and detergents are kept locked and inaccessible to residents in care. The washer/dryer appear to be in a good condition. Facility maintains a temperature of 77°F. The facility has six (6) private resident bedrooms (Rooms #1, 2, 3, 4, 6 & 7) and one room #5 for live-in staff. Resident rooms #1 #3 and #4 have direct exits to the outside. Bedrooms are appropriately furnished and have appropriate lighting. Bathrooms have soap, paper towels and all trash cans have a lid. Extra towels and linens were readily available. The hot water temperature measured at 111.4°F. There is one bathroom in the hallway between room #3 and #4. Bedrooms #4 and #7 have its own bathroom. The shared bathroom and the bathroom in room #7 have a shower with non-skid mat. Continue on LIC809-C The bathroom in room #4 has a tub with a non-skid mat. All bathrooms have grab bars. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 11:00am they were tested and observed to be operational. The exterior passageways were clean and clear of any obstructions. LPA observed a clean covered patio and backyard furniture to accommodate the six (6) residents. Facility has a permitted Accessory Dwelling Unit (ADU) in the backyard that is fenced all around with a gate and kept locked at all times. There are no bodies of water on the premises at the present time. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. Between 11:30am to 12:30am, LPA reviewed records of five (5) residents and three (3) staff. Resident and staff records appeared to be complete and updated. Resident’s files contain signed admission agreements and a medical assessment, and all other required documentation. LPA collected Certificate of Liability Insurance and LIC500. Administrator certificate is valid until December 2025. No deficiency cited during today's visit. Exit interview conducted and a copy of this report signed and delivered.