Routine inspection·April 2, 2025

At 1:30 p.m. on 04/02/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPAs met with staff and disclosed the reason for the visit. A file review was conducted prior to today’s visit. The facility was last visited on 04/16/2024 for an annual inspection. It is a single story building with four (04) bedrooms, two (02) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 nonambulatory residents, of which 1 may be bedridden in Bedroom #2. The facility serves residents with dementia. Approved hospice waivers for three (03). LPA observed a maintained front yard with a fruit-bearing tree and an unlocked front gate. Outside and inside the main entrance, LPA observed postings for emergency contacts, confidential complaint contacts, Ombudsman contacts, personal rights, theft and loss policy, administrator certificate, facility sketch with evacuation routes, “No Smoking – Oxygen in use” sign, visitation policy, activity schedule, and COVID postings. LPA observed a screening station with digital thermometer, visitor log, sanitizer, masks, and additional PPE. Walls, floors, windows, screens, and blinds were clean and in good repair. At 1:45 p.m. the house telephone was called and deemed operational. At 1:50 p.m. LPA measured the room temperature to be 75 degrees Fahrenheit. Two (02) residents were observed watching television in the living room together. One (01) resident was observed coloring at the dining room table. Reading materials, activity books, humidifier, and games were available near the dining room table. Furniture was in good condition. A closet with a sufficient supply of fresh linens and incontinence supplies was located in the hallway. The facility has four (04) bedrooms. One (01) bedroom is designated as a staff room. The staff room was unlocked and free of hazards. Resident bedrooms were all shared bedrooms. All bedrooms contained a chair, lamp, nightstand, storage, emergency lights, and a bed with adequate bedding. All furnishings were clean and in good condition. The facility has two (02) bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 2:10 p.m. LPA measured the water temperature to be 108.0 degrees Fahrenheit. LPAs observed an adequate supply of perishable and non-perishable supplies of food in the kitchen. The stove hood was clean. Appliances were in good condition. Sharps were locked below the counter. Cleaning solutions were locked below the sink. Medications were locked in a cabinet by the refrigerator. At approximately 2:20 p.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 08/16/2024. The garage was locked with an electronic number pad and contained cleaning solutions, extra supplies, an extra refrigerator, and a laundry area. A washing machine and dryer were observed inside. Both were in working order. LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition. Ramps were stable with secure handrails. Fruit bearing trees were present in the back yard. The emergency exit path was free from obstructions. The exit gate was unlocked. Auditory alarms were turned on and functioning. At approximately 3:00 p.m. smoke and carbon monoxide detectors were tested and operational. At 3:30 p.m. LPA reviewed resident and personnel 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 and safety risks were observed during today’s visit. Exit interview conducted. Copy of report provided.