Routine inspection·January 21, 2026

At approximately 12:00 p.m. on 01/21/2026, 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 11/27/24 for an annual visit. It is a single story building with seven (07) bedrooms, three (03) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which six (06) may be bedridden. The facility serves residents with dementia. Approved hospice waivers for four (04). Surveillance cameras are used in common and exterior areas. The main entrance was gated with a doorbell for entry. LPA observed a maintained front yard and a ramp in good condition leading to the main entrance. Postings at the front included COVID precautions, administrator certificate, facility license, facility sketch, confidential complaints contacts, ombudsman contacts, emergency disaster plan, rights of resident councils, personal rights, theft and loss policy, and “No smoking – Oxygen in use” sign. A screening station was located at the main entrance and contained a digital thermometer, visitor log, masks, and sanitizer. Walls, floors, windows, screens, and blinds were clean and in good repair. One (01) resident was observed in the dining room eating lunch. Three (03) residents were observed watching television and talking with one another. Two (02) residents were asleep for the duration of the visit. Two (02) staff members were observed cleaning and taking resident vital signs. A whiteboard was hung in the living room denoting the date, staff present, and meal times for the day. Board games, puzzles, reading materials, and exercise equipment were provided in the living room. A fireplace was covered and turned off. Medications were locked in a closet by numeric keypad near the main entrance. Two (02) hallway closets contained an adequate supply of extra linens and towels. A locked office in the rear of the facility contained personnel and resident files. The facility has seven (07) bedrooms. One (01) bedroom is designated as a staff room. The staff room was locked and free of hazards. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. The facility has three (03) bathrooms. One (01) bathroom is private to Bedroom #3, and two (02) are shared. 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 12:15 p.m. LPA measured the water temperature in the southern most bathroom to be 110.1 degrees Fahrenheit. LPA observed adequate supplies of perishable and non-perishable foods in the kitchen. Appliances were in good condition. The stove surface and hood were clean. Sharps and cleaning solutions were locked under the sink. LPA called out from the house telephone at approximately 12:45 p.m. The house telephone was deemed operational. LPA also observed wireless internet was available for resident use. The garage was locked and contained a washing machine and dryer in working order, detergents, chemicals, and extra supplies. LPA observed two (02) covered patio areas in the rear and side of the facility. The patios contained furniture in good condition along with potted plants and workout equipment. All emergency exit paths were free from obstructions. The exit gate was unlocked. Auditory alarms were turned on and functioning. Fire sprinklers were located throughout the facility. At approximately 1:10 p.m. LPA observed a fully charged fire extinguisher in the kitchen. A complete first aid kit was posted next to the fire extinguisher. At 1:30 p.m., smoke and carbon monoxide detectors were tested and operational. At 1:45 p.m. LPA reviewed staff and resident files. All files were complete and available for audit. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.