Routine inspection·July 25, 2025

At approximately 8:30 a.m. on 07/25/25, 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 07/26/24 for an annual visit. It is a single-story building with six (06) bedrooms, four (04) bathrooms, kitchen, garage, 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) may be bedridden in Bedroom #6. The facility serves residents with dementia. Approved hospice waivers for six (06) residents. Cameras are located in common and exterior areas. LPA conducted a file review of resident and personnel files at 8:40 a.m. All files were complete and available for audit.The front yard was maintained. At the main entrance, LPA observed postings for the activity calendar, resident rights, rights of resident councils, Ombudsman contact, confidential complaints, emergency disaster plan, house rules, neighborhood grievance policy, a blank copy of the admission agreement, administrator certificates, COVID precautions, facility sketch, and the facility license. A screening station contained a sign-in sheet, digital thermometer, and a visitor log. Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. A fireplace was appropriately covered. The hallway closet contained an adequate supply of fresh linens and towels. At approximately 10:15 a.m. LPA measured the room temperature to be 74 degrees Fahrenheit. The house telephone was called and determined functional at 10:20 a.m. Reading materials, television, exercise equipment, and art supplies were provided in the living room. All emergency exit paths were free from obstructions. Three (03) out of three (03) exit gates were unlocked. Ramps with secure hand rails led out from Bedroom #6 and a sliding glass door near the kitchen. At 10:30 a.m. the administrator tested the smoke and carbon monoxide detector to be operational. LPA observed an adequate supply of perishable and non-perishable food in the kitchen and garage refrigerators and freezers. The stove hood was clean. Medications were locked by the refrigerator. Sharp objects were locked under the counter top. Staff and LPA performed a medication review at approximately 10:45 a.m. for two (02) residents. Resident medications were maintained in the correct quantities. A washer and dryer were in good condition near the dining room. Detergents and cleaners were locked in the bathroom closest to the dining room. At 11:10 a.m. LPA observed a fully charged fire extinguisher near the laundry area. The facility has six (06) bedrooms. One (01) bedroom is designated for staff. The staff bedroom was locked and free of hazards. All bedrooms contained a night stand, lamp, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. Facility sketches with emergency evacuation routes were posted in each room and clearly labelled. All hospital-style beds had wheels in the locked position. The facility has four (04) bathrooms. All bathrooms contained liquid soap, paper towels, trash cans, grab bars near the toilet, shower, commode, and a non-skid mat in the shower. At 11:20 a.m. LPA measured the water temperature in the shared bathroom near Bedroom #6 to be 119.5 degrees Fahrenheit. The covered patio area contained furniture was in good condition. The back yard was maintained. The back yard contained a fountain with no water. A detached unit was locked and inaccessible. During today's inspection, the facility is in compliance with Title 22 regulations. No immediate health and safety risks were observed. Exit interview conducted. Copy of report provided.