Routine inspection·July 25, 2025

At 11:45 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, three (03) 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). 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, non-discrimination notice, visitation policy, administrator certificates, COVID precautions, facility sketch, and the facility license. 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 12:00 p.m. LPA measured the room temperature to be 76 degrees Fahrenheit. The house telephone was called at 12:15 p.m. and determined functional. Reading materials, puzzles, television, a piano, and art supplies were observed in the living room. LPA observed an adequate supply of perishable and non-perishable food in the kitchen and garage refrigerators and freezers. LPA also observed food preparation and plating for lunch. The stove hood was clean. Medications were locked by the refrigerator. Sharp objects were locked under the counter top. A washer and dryer in good condition were located near the kitchen. Detergents and cleaners were locked above the appliances. At 12:30 p.m. LPA observed a fully charged fire extinguisher near the laundry area. Staff and LPA conducted a medication review at approximately 12:35 p.m. for three (03) residents. All medications were maintained in the proper quantities. 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 labelled were posted in each room. The facility has three (03) bathrooms. All resident bathrooms contained liquid soap, paper towels, trash cans, grab bars near the toilet, shower, and commode, and a non-skid mat in the shower. At 12:55 p.m. LPA measured the water temperature in the shared bathroom near Bedroom #2 to be 119.1 degrees Fahrenheit. Two (02) out of two (02) emergency exit paths were free from obstructions. The exit gate was unlocked. Ramps with secure hand rails led out from Bedroom #5 and a sliding glass door near the living room. At 1:15 p.m. the administrator tested the smoke and carbon monoxide detector to be operational. The covered patio area contained furniture was in good condition. The back yard was maintained and contained a gardened area, a grill, and exercise equipment. The garage was locked and contained extra supplies. At 1:30 p.m. LPA reviewed resident and personnel files. All files were complete and available for audit. During today's inspection, the facility is 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.