Routine inspection·August 12, 2025

At 8:30 a.m. on 08/12/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the administrator and disclosed the reason for the visit. The facility was last visited on 07/23/24 for an annual visit. It is a single story building with six (06) bedrooms, three (03) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) residents, of which five (05) may be non-ambulatory and one (01) bedridden in Bedroom #4. The facility serves residents with dementia. Approved hospice waivers for six (06). LPA and the administrator toured the facility inside and out. The front yard was maintained with gardened areas. At the main entrance, LPA observed postings for the facility license, rights of resident councils, personal rights, resident rights, emergency disaster plan, confidential complaint contacts, ombudsman contacts, neighborhood complaint policy, house rules, administrator certificates, and a blank copy of the admission agreement. A sign indicating "No smoking - Oxygen in use" was posted on the front door and on the door to Bedroom #5. A screening station contained a visitor log, digital thermometer, and hand sanitizer. The facility has six (06) bedrooms. One (01) bedroom is designated as a staff room. The staff room was locked and free of hazards. All bedrooms contained a chair, nightstand, call button, appropriate lighting, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. All hospital-style beds had wheels in the locked position. Walls, floors, windows, screens, and blinds were clean and in good repair. At 10:10 a.m. LPA measured the room temperature to be 78 degrees Fahrenheit. The living room contained board games, puzzles, reading material, a television, and furniture in good condition. The fireplace was appropriately covered. Three (03) residents were observed watching television in the living room. Cameras were observed in common areas. At 10:15 a.m. LPA called the house telephone and verified that it was functioning properly. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen and the garage. The stove hood was clean. Appliances were in good condition. At approximately 10:30 a.m. LPA observed a fully charged fire extinguisher near the kitchen. Sharps were locked by the refrigerator. Cleaning solutions were locked above the washer and dryer. Medications were locked above the counter top. The washing machine and dryer were both in working order. LPA observed a covered patio area in the rear of the facility. The patio was shaded and contained furniture in good condition, extra equipment, and emergency water supplies. The ramp leading out was free of debris and had sturdy rails. Two (02) out of two (02) emergency exit paths were free from obstructions. Evacuation routes were posted and labelled. Five (05) out of five (05) auditory alarms were turned on and functioning. The garage was inaccessible and contained extra supplies and gardening tools. The facility has three (03) 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 10:45 a.m. LPA measured the water temperature in the shared bathroom to be 108.4 degrees Fahrenheit. At approximately 11:00 a.m., smoke and carbon monoxide detectors were tested and operational. Detectors functioned simultaneously, and the fire door in the hallway closed securely. At approximately 11:10 a.m., LPA and staff conducted a medication review for three (03) residents. All resident medications were maintained in the correct quantities. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed during today’s visit. Exit interview conducted. Copy of report provided.