Routine inspection·October 16, 2025

At approximately 12:20 p.m. on 10/16/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with Staff #1 (S1) and disclosed the reason for the visit. LPA and S1 toured the facility inside and out. The facility was last visited on 08/22/24 for an annual visit. It is a single story building with seven (07) bedrooms, four (04) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which six (06) may be bedridden. The facility serves residents with dementia. Approved hospice waivers for four (04). Surveillance cameras are used in common and exterior areas. The front entrance is gated and unlocked. Shaded seating areas were observed at the front and rear of the facility. At the main entrance, LPA observed postings for the house rules, facility sketch, administrator certificate, facility license, emergency disaster plan, COVID precautions, personal rights, theft and loss policy, rights of resident councils, confidential complaint contacts, ombudsman contacts, and oxygen-in-use signs. A screening station at the front contained a visitor log and sanitizer. Walls, floors, windows, screens, and blinds were clean and in good repair. At 12:30 p.m. LPA measured the room temperature to be 77 degrees Fahrenheit. The living room contained a television, reading materials, exercise equipment, and furniture in good repair. At 12:40 p.m. the house telephone was called and deemed operational. 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. Exit doors from rooms were unlocked. Six (06) out of six (06) auditory alarms in resident bedrooms were tested and functioning. Ramps leading out were secure, and emergency exit paths were free of debris or hazards. The back yard contained a gardened area and an unlocked exit gate. The storage shed was locked and contained tools and chemical cleaners. Interview with S1 at approximately 1:00 p.m. revealed the large tree had recently been removed form the back yard. A secondary living room contained a piano and a treadmill. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen refrigerator and freezer. Appliances were in good condition. Sharps were locked below the counter top. Cleaning solutions were locked below the sink. Medications and confidential files were locked in separate cabinets. The garage was unlocked and contained a washing machine, a dryer, and extra supplies. Both appliances were in working order. Detergents were locked above them in a cabinet. The facility has four (04) bathrooms. One (01) bathroom is private, and three (03) are shared. All bathrooms contained liquid soap, trash cans with tight fitting lids, grab bars near the toilet and shower or commodes, and a non-skid mat in the shower. At approximately 1:10 p.m. LPA measured the water temperature to be 105.1 degrees Fahrenheit in one of the shared bathrooms. At approximately 1:20 p.m., smoke and carbon monoxide detectors were tested and operational. At approximately 1:25 p.m. LPA observed a fully charged fire extinguisher in the kitchen. It was purchased in 2025 as indicated by the date on the bottom, though it did not have a receipt attached. At 1:30 p.m. LPA conducted a records review of resident and personnel files. All files were complete and available for audit. During today’s inspection, no immediate health or safety concerns were observed. Exit interview conducted. Copy of report provided.