Routine inspection·July 14, 2025

Licensing Program Analyst (LPA) Evelin Rios conducted a required unannounced annual visit at this facility. LPA met with the administrator Eva Calko who granted access and LPA explained the purpose of the visit. A tour of the physical plant was conducted at approximately 01:40 p.m., with the administrator and the following was observed: Upon entry LPA observed appropriate postings along a wall by the front door. Kitchen: LPA conducted a tour of the kitchen and observed there to be a sufficient supply of two day perishables and seven day non-perishable foods. Food that was opened and stored in tupperware was properly labeled. Food storage and preparation areas were clean. LPA observed all knives and sharp objects, locked in a kitchen cart drawer inaccessible to residents in care. There is one (1) fire extinguisher located by the kitchen, observed fully charged with service date 06/20/2025. LPA observed the first aid kit in a kitchen cabinet. Common areas: LPA observed the living area and dining area to be clean. The furniture was in good repair and the couch, recliners and dinning table sits the capacity of the facility. Surrounding Grounds : Entry and exits were free of obstructions. There is a covered patio with appropriate furniture for residents to use. There are no bodies of water. (Continue to LIC809-C) Bedrooms: LPA inspected three (3) resident bedrooms. Three (3) out of three (3) bedrooms are for private use. LPA observed occupied rooms to be properly furnished with beds, appropriate night stand, chair, bedding and have sufficient lighting and storage. Bathrooms: The facility has two (2) bathrooms. One (1) is for residents' use. LPA observed resident bathroom to be clean and properly supplied with hand soap, toilet paper, and paper towels. LPA observed a non skid shower mat and proper grab bars by shower and toilet. At 3:28 p.m., LPA tested the hot water temperature in the residents' bathroom and it read 118.4 degrees Fahrenheit, within regulation. Laundry : The laundry room is accessible to residents and leads to the garage. The garage is maintained locked. The facility keeps detergents and cleaning supplies locked in a cabinet in the laundry room. LPA observed the administrator test a smoke detector at 3:26 p.m. Smoke detectors are interconnected located through out the facility. LPA observed detectors functioning properly. LPA observed fire doors close automatically when smoke detector was tested. LPA observed auditory door alarms on exit doors, on and functioning properly. LPA observed one (1) carbon monoxide detector and it was functioning properly. Resident/Staff Records: At approximately 1:58 p.m., LPA reviewed two (02) of two (02) resident records for compliance with licensing forms. Review of records revealed one (01) of two (02) residents was recently admitted to hospice on 01/22/25, but a reappraisal was not documented. According to administrator resident#1's (R1's) change in condition and assessment was based on Hospice evaluation. At 2:33 p.m., LPA reviewed two (02) staff records to insure compliance with licensing forms and to verify up-to-date training. Administrator will send an email to Guardian Background Check System and include LPA regarding application for administrator's family member residing in the facility. Centrally stored medications are maintained locked in a hallway closet. Centrally Stored Medication and Destruction Records were reviewed. Facility keeps written records and Medication Administration Records (MARs). Technical Violations issued (refer to LIC9102). Exit Interview Conducted. A copy of this report provided.