Routine inspection·October 10, 2025

At approximately 12:45 p.m. on 10/10/2025, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out. The facility was last visited on 09/05/24 for an annual inspection. It is a single story building with four (04) bedrooms, two (02) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for five nonambulatory (05) residents, of which one (01) may be bedridden in Bedroom #2. The facility serves residents with dementia. Approved hospice waivers for four (04). At the main entrance, LPA observed an unlocked gate, exercise equipment, a shaded seating area, and a ramp leading to the front with sturdy handrails. LPA observed postings for confidential complaint contacts, emergency contacts, ombudsman contacts, personal rights, rights of resident councils, emergency disaster plan, facility sketch with evacuation routes labeled, administrator certificate, and facility license. Walls, floors, windows, screens, and blinds were clean and in good repair. At 12:55 p.m. LPA measured the room temperature to be 79 degrees Fahrenheit. The living room contained furniture in good repair, an appropriately covered fireplace, games, puzzles, reading material, music, and television. The hallway closet contained additional hygiene supplies. A camera was used to monitor the living area. Four (04) out of four (04) residents were observed relaxing in the living room. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen and dining area. The stove hood was clean. Appliances were in good condition. Sharps were locked above the countertop. Cleaning solutions were locked next to the sharps. Medications were locked in a separate cabinet in the dining area. A washing machine and dryer were located outside of the kitchen. Both were in working order. Detergents were locked above the appliances. The facility has four (04) bedrooms. One (01) bedroom is designated as a staff room. The staff room was locked and free of hazards. All bedrooms contained a chair, appropriate lighting, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. Two cracks were observed in the ceiling in the hallway and in Bedroom #3. Interview with Staff #1 (S1) at approximately 1:15 p.m. revealed a maintenance man caused the cracks when fixing the air conditioning. S1 noted they will consult with the property owner about repairs. At 1:20 p.m. S1 called the house telephone and verified that it is operating. The facility has two (02) bathrooms. 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 1:30 p.m. LPA measured the water temperature to be 105.4 degrees Fahrenheit. All emergency exit paths were free from obstructions. Exit gates were unlocked with self-closing latches. Four (04) out of four (04) auditory alarms were turned on and functioning. S1 noted that the facility recently installed a centralized auditory alarm system. At approximately 1:45 p.m., smoke and carbon monoxide detectors were tested and operational. At approximately 1:50 a.m. LPA observed a fully charged fire extinguisher in the kitchen. LPA observed a shaded patio area in the front of the facility. The patio contained furniture in good condition. Ramps leading out were free of tripping hazards and had secure hand rails. The back yard contained fruit-bearing trees and exercise equipment. At 2:00 p.m., LPA conducted a file review of resident and personnel records. All files were available for audit. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed. Exit interview conducted. Copy of report provided.