Routine inspection·April 16, 2025

Licensing Program Analyst (LPA) Abeye Duguma met with the Executive Director, Angela Smith, for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 10:30a.m. and the following was noted: There is one entrance being utilized at the facility. The facility is fire cleared for one hundred ninety-nine (199) residents of which one hundred (100) may be non-ambulatory on the first floor in rooms #1-8, 25-30, 51-71 and 87-88 and 30 bedridden in rooms #72-86. The second and third floors are for ambulatory only and the facility has a hospice waiver for thirty (30). The facility is currently occupying one hundred sixty-nine (169) residents. The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. The garage is currently being used for parking and storage. Laundry detergents, cleaning agents and other toxins are locked away. Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. The common and dining areas are neat and clean. The facility maintains an average comfortable temperature at 73°F. The smoke and carbon monoxide detectors are hardwired, interconnected and centralized. The alarm automatically sends a signal to the local fire department. Fire extinguishers are located throughout the facility and observed to be fully charged and last inspected 10/21/2024. (continued on LIC 809-C) The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at an average 117.8°F. Towels and washcloths are not shared. There was enough clean linen available. LPA observed medication to be inaccessible to residents. Facility maintains complete first aid kits. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.