Routine inspection·February 20, 2026

At 11:40 a.m. on 02/20/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and later the administrator and disclosed the reason for the visit. A file review was conducted prior to today’s visit. The facility was last visited on 01/22/26 for a complaint visit. It is a single story building with six (06) bedrooms, four (04) bathrooms, kitchen, laundry room, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which one (01) may be bedridden. Approved hospice waivers for two (02). The facility serves residents with dementia. Four (04) out of four (04) auditory alarms were observed on and functioning LPA observed a maintained front yard with gardened plants. The front gate was unlocked. A screening station at the front contained surgical masks, sanitizer, a digital thermometer, and a visitor log. Postings at the front and near the office area included COVID precautions, visitation policy, facility license, confidential complaints contacts, ombudsman contacts, emergency disaster plan, rights of resident councils, personal rights, theft and loss policy, and the facility sketch. Walls, floors, windows, screens, and blinds were clean and in good repair. The living room was clean and had furniture in good repair, board games, art supplies, and reading materials. Hallway closets contained an adequate supply of fresh linens. Another closet was locked and contained cleaning supplies and PPE. The laundry area was locked and contained an operable washer and dryer and detergents. The office area contained locked medications and confidential files. At approximately 12:20 p.m., LPA conducted a medication review for two (02) out of four (04) residents. All medications were stored in the correct quantities. The facility has six (06) 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, and a bed with adequate bedding. All furnishings were clean and in good condition. Rooms with hospital beds had wheels in the locked position. Bedroom #3 had oxygen equipment set up and a sign posted on the door indicating “No Smoking – Oxygen in Use”. LPA used the house telephone at 12:30 p.m. to call out. The phone was deemed operational. Adequate supplies of perishable and non-perishable foods were observed in the kitchen refrigerator and freezer and an additional refrigerator outside. Appliances were in good condition. The stove surface and hood were clean. Sharps were locked below the counter top and cleaners were locked below the sink. At 12:35 p.m. LPA observed a fully charged fire extinguisher. It was last inspected on 05/07/25 and had a tag attached. The facility has four (04) bathrooms. One (01) bathroom is private to Bedroom #3. Shared bathrooms were located near Bedroom #2 and near the staff bedroom. All bathrooms contained liquid soap, paper towels, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 12:45 p.m. LPA measured the water temperature to be 108.9 degrees Fahrenheit in the bathroom private to Bedroom #3. In the rear of the facility, LPA observed a patio area which contained furniture in good condition, gardened areas, and fruit trees. Walkways were free of hazards. The exit gate was unlocked. At approximately 1:00 p.m., smoke and carbon monoxide detectors were tested and operational. At 1:10 p.m. LPA reviewed staff and resident files. All files were complete and available for audit. No immediate health or safety hazards were observed during today’s visit. The facility is in compliance with Title 22 Regulations. Exit interview conducted. Copy of report provided.