Routine inspection·July 24, 2025

At approximately 11:40 a.m. on 07/24/25, 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 07/09/2024 for an annual inspection. It is a single story building with seven (07) bedrooms, five (05) 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) bedridden in Bedroom #6. The facility serves residents with dementia. Approved hospice waivers for six (06). LPA reviewed resident and personnel files, including home health and hospice files, at 11:45 a.m. All files were complete and available for audit. At the main entrance, LPA observed a visitor’s log, hand sanitizer, and postings for confidential complaint contacts, Ombudsman contact information, personal rights, rights of resident councils, neighborhood grievance procedures, house rules, facility sketch with evacuation routes clearly labelled, emergency disaster plan, admission agreement, administrator certificate, and the facility license. Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. Two (02) residents were observed watching television in the living room. A piano, reading material, art supplies, and exercise equipment were provided in the living room. Sufficient amounts of fresh linens, emergency water, and hygiene supplies were stored in the hallway cabinets. Cameras were used in common and exterior areas. LPA observed an adequate supply of perishable and non-perishable food in refrigerators, freezers, and pantries in the kitchen and the garage. The stove hood clean was free from debris. Appliances were in good condition. Sharps were locked in a drawer below the counter. Medications were locked above the counter. LPA observed a washing machine and a dryer in good condition in the laundry area. Detergents were locked near the appliances. Staff and LPA conducted a medication review for three (03) residents at approximately 1:00 p.m. All resident medications were stored and accounted for in the correct quantities. At approximately 1:30 p.m., five (05) out of five (05) auditory alarms were tested and deemed operational. All emergency exit paths were free from obstructions. The exit gate was unlocked with a self-closing latch. At approximately 2:00 p.m., the dual-purpose smoke and carbon monoxide detector in the hallway was tested and operational. When tested, the fire door in the living room released from its magnetic suspension. At 2:05 p.m. the house telephone was called and deemed operational. At approximately 2:10 p.m. a fully charged fire extinguisher was observed in the laundry area. The facility has seven (07) bedrooms. One (01) bedroom is designated for staff. The staff room was locked and free from hazards. All six (06) resident bedrooms are private. All bedrooms contained a chair, nightstand, lighting, storage, and bed with adequate bedding. All furnishings were clean and in good condition. The facility has five (05) bathrooms. Four (04) bathrooms were private and one (01) is shared bathroom. All bathrooms contained liquid soap, paper towels, trash can with a tight fitting lid, grab bars near the toilet or commode, and a non-skid mat in the shower. At approximately 2:20 p.m. LPA measured the water temperature in the shared bathroom to be 111.6 degrees Fahrenheit. LPA observed a covered patio area with furniture in good condition. A ramp with a sturdy handrail led out to the exit. A gardening area was available in the rear of the facility. A gas grill was also present. During today's inspection, the facility is in compliance with Title 22 regulations. No immediate health or safety hazards were noted at the time of the visit. Exit interview conducted. Copy of report provided.