Routine inspection·September 9, 2025

On 09/09/25, 10:15 am, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced annual inspection visit. LPA met with the Administrator, and reason for the visit was discussed. Facility is licensed as a single-story residence, fire clearance for six (6) non-ambulatory; Of which, one (1) may be bedridden in room#1. Hospice waiver for six (6). Facility has three (3) bedrooms and three (3) bathrooms. At 10:35 am , LPA conducted a tour of the physical plant with the Administrator and observed the following: Physical plant was inspected for cleanliness and condition . Facility’s main door is the primary entry/exit access. Screening area is located immediately upon entrance. Auditory alarm sensors are present on all exits. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Room temperature is comfortable; wall thermostat displays a setting of 74.0°F ., within the required range. Approved Mitigation and Infection Control plan is on file. Hand washing, coughing etiquette, and other necessary signage are prominently displayed throughout the facility. Required postings observed to be current. Disaster drills were last conducted: September, 2025. Kitchen area is clean and clear of clutter. LPA observed refrigerator, microwave, stove/oven, dishwasher, and sink to be operational. Knives/Sharps are stored in a locked kitchen drawer inaccessible to residents. A two-day supply of perishable food was observed as properly stored and labeled. A seven-day supply of nonperishable food is stored and available . Dish soap, cleaning solutions, and toxins are stored in a locked lower cabinet underneath the kitchen sink and inaccessible to residents. [LIC 809C-continued] Fire Detection/Protection system is present in the facility. Multiple dual smoke alarm/ carbon monoxide detectors are installed, hardwired, and interconnected. Detectors were tested and function properly. LPA observed two (2) fire extinguishers located in the front and rear areas of the facilit y. Extinguishers indicate full charge; display service date: 02/07/2025. Medications are stored in a secured medication cart in den area adjacent to the kitchen and inaccessible to residents. Medications are listed on a centrally stored medication and destruction record log. A First Aid kit is complete and stored inside the medication cart. Laundry At 11:30 AM, LPA observed laundry area located in the hallway, across from bedroom #1. Laundry is secured by an electric rolling shutter activated by a key switch only accessible to staff. Laundry soaps and other cleaning agents are stored and inaccessible to residents. Hallway area storage cabinets were observed to contain fresh towels, linens and blankets, sufficient for residents. Commons: LPA observed living room area as clean, organized and clear of obstruction. Furnishings observed in good condition and provide adequate seating for residents. Activities were observed as stored in a dresser located in the living room which contains arts and crafts, board games, puzzles etc. Bedrooms are observed as clean with sufficient lighting, properly furnished with sufficient closet space, bedding, linens, at least one chair, and nightstand. Bathrooms were observed to be clean and sanitary with necessary personal hygiene supplies and required safety fixtures (grab bars, anti-slip floor striping). Hot water temperature measured at 110.0°F. Within the required range. Towels and washcloths are not shared. Garage is detached from the house and observed to be locked and inaccessible to residents. Garage stores emergency water, incontinence and PPE supplies. Outdoor (backyard) area observed to have a shaded patio, with tables and seating sufficient for residents and visitors. Outdoor furniture was observed to be in good condition. There are no bodies of water in the facility. [LIC 809C-continued] Resident records are stored in secured\locked hallway cabinet and inaccessible to residents. Records were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. Resident records appeared to be complete and current. Staff records are stored in secured office area and inaccessible to residents. Staff files contain criminal record clearances and are associated to this facility. Staff records appear to be complete and current. There were no health and safety hazards observed during this inspection. Exit interview conducted and a copy of this report was given.