Routine inspection·November 8, 2025

On 11/08/25, Licensing Program Analyst (LPA) Regina Cloyd conducted an required – annual inspection and met with Staff and Supervisor Joel Morales. Facility is licensed to serve six (6) non-ambulatory residents and has an approved hospice waiver for six (6) residents. The facility has two bathrooms, four bedrooms (two rooms are shared), staff room, kitchen, living room, dining rooms, two outdoor patios, and laundry room. Staff accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Resident bathrooms were checked. Toilets and water faucets worked properly, shower was free of mold/mildew and a non-skid mat was in place. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Continue to LIC809-C. Common areas were clean and clear of hazards. Doorways were free of obstructions. LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in locked storage cabinet. First Aid kit was available. Two fire extinguisher, last serviced April 2025, was observed in the kitchen and near bedroom #4. The Supervisor tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional. Five staff records were reviewed, five out of five staff records had required criminal record clearances or criminal record exemptions. Three resident records were reviewed and, three out of three resident records had medical assessments/hospice plan of care. Two residents’ medication was reviewed. Deficiencies are being cited. During record review, LPA did not observe 20 hours of annual training for Staff #2 - #5. The last training documents on file are from September 2024. An exit interview was conducted, plans of correction developed, technical assistance provided, and a copy of this report with appeal rights was discussed and left with Staff Tula Thaxter.