Routine inspection·September 28, 2025

On 09/28/25 at 10:21AM, Licensing Program Analyst (LPA) Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo met with Caregiver, Phillip Pryce and disclosed the purpose of the visit. The Administrator, Marilyn Clanton, arrived about forty (40) minutes later. LPA asked for the census, resident, and staff files. A physical tour was conducted at 10:30am and observed the following: The Kitchen area was toured, and LPA observed there to be sufficient seven (7) day supply of non-perishable foods and perishable food for all residents. The kitchen area was clean at the time of the tour. The fire extinguisher is located against the wall on your right-hand side of the kitchen. It is fully charged dated 09/2025. There is extra, food emergency kits in the kitchen and in the kitchen pantry. The sharps are locked and inaccessible to the residents in one (1) of the right side cabinets and chemicals/toxins are also kept in this area that are locked and inaccessible to the residents. The medication is also locked and inaccessible to the residents on the left hand side of a cabinet in the hallway. Outside/Backyard: There is a ramp in the back of the facility. The outside/backyard has furniture for residents with proper seating. The facility has a cameras in common areas. The facility has no pool or bodies of water. There is no garage. LIC 809C-continued Bedrooms and Bathrooms: There are six (6) bedrooms and two (2) bathrooms.. There are six (6) bedrooms that are for resident use with no bathroom. Two (2) bedrooms are currently unoccupied. All bedrooms and bathrooms were toured and were properly furnished and have appropriate bedding, linens, toiletry and lightning. The bathrooms have proper toiletry and grab bars. There are chemicals/toxins that are kept in this area also in a cabinet that are locked and inaccessible to the residents. The bathroom temperatures of the water are within regulations reading at 115 degrees Fahrenheit. There is no staff bedroom. There is also an office that is locked in the hallway. The dining area/living room area has enough seating for the residents and the staff. There is a large television against the wall and there is also internet access and telephone access. There is another fire extinguisher in this area dated 09/2025. There is one (1) washer and dryer that is kept in the hallway. The carbon monoxide and smoke detectors are located throughout the facility and are operable and interconnected. The house temperature is set at 72 degrees. There are two (2) more fire extinguishers down the hallways dated 09/2025. Administrative: At the entrance of the facility against the wall, there is YES signs, Emergency Disaster Plan, Patient Rights, Personal Rights, Facility Sketch, Ombudsman sign, Oxygen sign, no smoking, the insurance plan is updated and is dated 12/19/2025. The last emergency disaster drill was July of 2025. Staff and Resident Files were reviewed: Three (3) out of three (3) staff files were reviewed. Six (6) out of six (6) resident files were reviewed. Four resident files were missing physician's report/tuberculosis, Six resident files were missing resident appraisal, pre-appraisal, functional capabilities and appraisal needs and services. An exit interview was conducted, citation(s) were issued, appeal rights was provided and a copy of this report was given to the administrator.