Routine inspection·January 31, 2026

On 1/31/26, 8:00 am, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced annual visit to this facility. LPA met with Facility Administrator, and reason for the visit was discussed. Facility is licensed as a single-story residence. Fire clearance approved for six (6) Non-ambulatory residents, and one (1) bedridden. Hospice waiver for six (6). Facility has six (6) total bedrooms, (four private bedrooms, one shared bedroom, and one staff bedroom) with four (4) total bathrooms. At 8:20 am, LPA conducted a tour of physical plant with the Administrator and observed the following: Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Screening area is located immediately upon entrance. Visitor sign-in sheet, hand sanitizer, gloves and masks are available. Room temperature is comfortable; wall thermostat displays a setting of 72.0°F., within the required range. An approved Mitigation and Infection Control plan is on file. Hand washing, coughing etiquette, and other necessary signage are prominently displayed throughout the facility. Required postings observed to be current. Disaster drills were last conducted on 1/02/26. Fire Detection/Protection system is present in the facility. Dual Smoke and Carbon Monoxide detectors were tested and function properly. LPA observed two (2) fire extinguishers located in the dining room, and in the hallway. Extinguishers display service date: 12/25/25. [LIC 809-C Continued] Kitchen: At 09:00 am, LPA observed kitchen as clean, equipped with a functional stove, refrigerator, a second refrigerator, (located in hallway near bedroom #05), multiple appliances, with adequate supply of perishables and non-perishable food. Emergency food is stored in a cabinet located adjacent to the kitchen. Food is observed as properly labeled and stored. Kitchen cabinets store dishes, plastic, paper goods and utensils. Knives and sharps are secured in a locked kitchen drawer and inaccessible to residents. Medications At 9:20 am, LPA observed a secured medication cart, located in hallway area near bedroom#1. Medications are listed on a centrally stored medication and destruction record log. A stocked first aid kit and manual was observed in hallway area cabinets. Laundry area is located near bedroom#01. Laundry soaps and other cleaning agents are stored and inaccessible to residents. LPA observed two storage cabinets located near bedroom#6. Each storage room contains PPE, incontinent supplies, personal care items, linens, mattress pads, comforters, towels, clean linen and blankets sufficient for residents. Commons: LPA observed living room and resident dining area. Common areas observed as clean and organized. Furniture provides adequate seating for residents and is in good condition. Activities are observed in living room area dresser which stores arts and crafts, board games, puzzles etc. Bedrooms are observed as clean, with sufficient lighting, properly furnished with sufficient closet space, bedding, linens, at least one chair, and night stand. Bathrooms were observed to be clean and sanitary, with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hand towels and washcloths are not shared. Hot water temperature measured at 116°F., Within the required range. Garage is attached and observed to be locked and inaccessible to residents. Garage stores bedroom furniture, wheelchairs, and medical equipment. Outdoor At 10:10 am, LPA observed outdoor area to have a shaded patio, with table with sufficient seating for the residents. Outdoor furniture observed to be in good condition. All trash cans were observed to be covered. There are no bodies of water in the facility. [LIC 809-C Continued] Resident records: Cabinets in the living room area are locked and inaccessible to residents . A total of five (5) Resident files were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. LPA observed that file for Resident #3 (R3) did not contain record of tuberculosis tests or chest exams. This deficiency is cited on the corresponding LIC 809-D page. Staff records: Cabinets in the living room area are locked and inaccessible to residents . A total of four (4) Staff files were reviewed. Criminal record clearances were present, and Staff are associated to this facility. LPA observed that file for staff #2 and staff#3 are incomplete; records are missing Health Screening Report (LIC503) This deficiency is cited on the corresponding LIC 809-D page. An exit interview was conducted, deficiencies were issued, appeals rights and a copy of this report was provided to the administrator.