Routine inspection·August 25, 2025

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Cherie Wood and explained the reason for the visit. The facility is licensed to serve 6 residents age 60 and over of which 2 may be non-ambulatory and 2 may be bedridden in room #5 with a hospice waiver for 4. The facility is located in a residential area and consist of a single home with (4) resident bedrooms, (3) bathrooms, (1) staff bedroom, a living room, a dining room, a kitchen, a laundry area, an attached garage a front yard, and a back yard. The following domains were reviewed during this visit: Infection Control : Facility maintains a copy of the infection control plan. All staff have a TB clearance. Operational Requirements: Facility maintains a plan of operation, fire clearance. Facility is operating within the limitations of their license. They currently don't any residents under hospice care, home health, or bedridden. A current liability insurance was observed and a copy was obtained. Physical Plant/Environmental Safety: LPA toured the facility with Cherie Wood and observed the following. Facility was observed in good repair. Living room and dining room were observed with furniture and in good repair. Kitchen was observed clean. Cleaning supplies and sharps are maintained in a locked drawer, sharps magnetic lock was observed slightly out of place. Refrigerator/freezer and pantry were observed. Medication cabinet is located across from the kitchen. Four (4) resident rooms were observed with sufficient lighting, required furniture and bedding supplies. Half bed rails were observed in Resident #1,2,3, and 5 beds, here is no physician's request on file. Three (3) bathrooms were observed in good repair and clean. Water temperature was tested in each bathroom sink and tested between 109.0-113.3 degrees F., which is within the required 105-120 degrees F. A fire extinguisher was observed. Carbon Monoxide/Smoke detectors were tested and are in working condition. (CONTINUED ON LIC 809C) Laundry area was observed in good repair. Facility maintains linens. No large bodies of water were observed. Passageways were clear of obstructions. Staffing: Administrator certificate was reviewed for Cherie Wood #7010587740 exp. date: 8/19/27. CPR/First aid training was observed for staff. Staff is on duty during the night shift. Personnel Records/Staff Training: LPA reviewed 5 staff files. Files were available for review. Files include; TB clearance, health screening, background clearance, personnel record, and training for each staff. Two staff were interviewed. Resident Rights/Information: License, Let us Know (PUB 475), Ombudsman, personal rights posters were posted in home's common area. Planned Activities: Facility provides activities such as puzzles, books. Food Services: LPA observed at least 2 days of perishables and 7 days of non- perishable food supplies. An additional refrigerator was observed in the garage. Kitchen was observed clean and free of pest. Three residents have a modified diet per medical assessments. Incidental Medical and Dental: Facility provides assistance with medical/dental arrangements and with medication assistance. Medications were observed stored in locked medication closet. LPA reviewed medication for 5 residents. Resident Records/Incident Reports: LPA reviewed 5 residents files, each contained admission agreement, medical assessment, TB clearance, pre-appraisal, and appraisal. Two resident were interviewed. Disaster Preparedness: LPA reviewed emergency disaster plan LIC 610E(3/19) last reviewed on 8/1/25. Emergency drills are conducted quarterly, last emergency drill was conducted on 8/1/25. Emergency food supplies were observed. Residents with Special Health Needs: Facility is not serving residents with Special Health Needs. Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Cherie Wood and a copy of this report, LIC 809D, and appeal rights were provided.