Routine inspection·September 17, 2025

At 11:55am, Licensing Program Analyst (LPA) Angela Panushkina arrived at the facility to conduct an annual inspection. LPA met with the Administrator and explained the reason for the visit. A tour of the physical plant was initiated at 12:00pm and the following was observed: The facility is cleared for five (5) Non-Ambulatory (in rooms #1, #2 and #3) and one (1) Bedridden resident in room #5. 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 purchased on 07/16/2025. Medications and resident/staff files are kept in kitchen cabinet. There is a complete first-aid kit in the cabinet with all required supplies and with the first aid manual. Bedrooms: The facility has a total of six (6) bedrooms, five (5) of which are designated for residents use, one (1) room is designated for live-in staff. and three (3) bathrooms. The bedrooms are appropriately furnished with sufficient closet space and have sufficient lighting. All exit doors will have an auditory alarm. Bathrooms: Facility has three (3) 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 111.7°F. Continue on LIC809-C The facility maintains a comfortable temperature of 77°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 1:00pm 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. There is a swimming pool that is fenced with a gate that will be kept locked at all times. The fence installed to keep residents out of the swimming pool area is approximately 5 feet high throughout the parameters. You will need a key to unlock the padlock to gain entry to the swimming pool as it is kept locked at all times. Between 1:10pm to 2:00pm, LPA reviewed records of six (6) residents and three (3) staff. Resident and staff records appeared to be complete and updated. Resident’s files contain signed admission agreements and a medical assessment, and all other required documentarians. Annual fee is paid in full. LPA observed Administrator certificated renewed on 07/17/2025 with an expiration date of 07/16/2027. LPA collected Certificate of Liability Insurance and LIC500. No citations issued during this visit. Exit interview conducted and copy of this report signed and delivered.