Routine inspection·September 10, 2025

At 11:30am, Licensing Program Analyst (LPA) Angela Panushkina arrived at the facility to conduct an unannounced annual inspection. LPA met with the Administrator and explained the reason for the visit. A tour of the physical plant was initiated at 11:35am and the following was observed: The Fire Clearance is approved for a maximum capacity of six (6) residents, of which five (5) can be Non-Ambulatory and one (1) Bedridden residents. Hospice waiver for six (6) residents is also approved. Kitchen: The kitchen area is equipped with a refrigerator, microwave oven and sink. LPA observed there to be sufficient stock of one-week perishable foods and two-day non-perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. All knives were observed to be locked in the kitchen drawer. The fire extinguisher was last serviced on 07/10/2025. Bedrooms: The facility has five (5) bedrooms designated for residents’ use. The bedrooms are appropriately furnished with sufficient closet space and have sufficient lighting. All exit doors will have an auditory alarm. The facility has awake staff Bathrooms: Facility has two (2) bathrooms. Bathrooms have soap, paper towels and hand washing signs were observed. Bathrooms have soap, paper towels and all trash cans have a lid. Extra towels and linens were readily available. The hot water temperature measured at 105.4°F Common Areas: Medications and resident/staff files are kept in a metal, file cabinet, located by the kitchen and kept locked and inaccessible to residents in care. There is a complete first-aid kit in the cabinet with all required supplies and with the first aid manual. Continue on LIC809-C The facility maintains a comfortable temperature of 73°F. LPA observed all common areas are furnished with adequate furniture to accommodate a maximum capacity of six (6) residents. There is a functioning telephone on the premises. Smoke detectors carbon monoxide is located throughout the facility and at 12:30pm they were tested and observed to be operational. Laundry Room: The laundry is located in the garage. The washer/dryer appears to be in good condition. Laundry supplies are kept inaccessible when not in use with supervision. Outside Areas: The back of the facility has sufficient yard space. LPA observed appropriate outdoor furniture, with a covered shaded area for the residents. The outdoor area is free of visible immediate hazards. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water. Between 12:30am to 1:30am, LPA reviewed records of LPA reviewed records of six (6) residents and three (3) staff. Residents and staff records appeared to be complete and updated. Residents’ files contain signed admission agreements, medical assessment, and all other required documentation. Annual fee is paid in full. LPA observed Administrator certificated renewed on 05/30/25 with an expiration date of 05/29/27 No citations issued during today's visit. Exit interview conducted and copy of this report signed and delivered.