Routine inspection·April 24, 2026

At approximately 8:45 a.m. on 04/24/26, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the administrator and disclosed the reason for the visit. A file review was conducted prior to today’s visit. The facility was last visited on 04/24/25 for an annual inspection. It is a single story building with three (03) bedrooms, two (02) bathrooms, kitchen, laundry area, common areas, and outdoor areas. It has an approved fire clearance for two (02) ambulatory residents and four (04) nonambulatory residents, of which one (01) may be bedridden in Bedroom #3. Approved hospice waivers for six (06). LPA observed a maintained front yard and an unlocked perimeter gate with a parking lot in the front. A screening station at the front contained surgical masks, sanitizer, a digital thermometer, and a visitor log. Postings at the front and in the kitchen included the facility license, confidential complaints contacts, ombudsman contacts, emergency disaster plan, rights of resident councils, personal rights, weekly menu, activity schedule, theft and loss policy, house rules, the most recent licensing report, and the facility sketch. LPA observed an adequate supply of perishable, non-perishable, and emergency foods in the kitchen refrigerator, freezer, and cupboards. Appliances were in good condition. Sharps were locked above the counter top. At approximately 9:10 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It was purchased on 04/04/26 as shown by the administrator's receipt. Medications were locked above the counter. The stove surface and hood were clean. LPA conducted a medication review at approximately 9:15 a.m. for two (02) residents. Two (02) out of two (02) resident medications were maintained in the proper quantities. Walls, floors, windows, screens, and blinds were clean and in good repair. At 9:40 a.m. LPA measured the room temperature to be 71 degrees Fahrenheit. A fireplace was appropriately covered. Board games, art supplies, and a television were also provided in the living room. The facility has three (03) bedrooms. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. All rooms with hospital beds had wheels in the locked position. The facility has two (02) bathrooms. One (01) bathroom was private to Bedroom #1. 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 10:00 a.m. LPA measured the water temperature in the shared to be 107.8 degrees Fahrenheit. A washing machine and dryer were located in the laundry area outside of the kitchen. Both were in working order. Detergents and cleaning supplies were locked above the appliances. LPA observed a patio area in the rear of the facility. The patio contained furniture in good condition and an electric piano. Additional shaded seating was located in the front and back yards. The garage was locked and contained extra supplies. The administrator called the house telephone at 10:15 a.m. The phone was deemed operational. The emergency exit path was free from obstructions. Four (04) out of four (04) auditory alarms at the front were turned on and functioning. At 10:30 a.m., smoke and carbon monoxide detectors were tested and operational. Detectors functioned simultaneously when tested. At 10:50 a.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 hazards were observed. Exit interview conducted. Copy of report provided.