Routine inspection·February 3, 2025

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting the required one year annual inspection. LPA Haley was greeted and granted entry by staff who contacted the Licensee/Administrator (AD) via telephone. AD Fisk arrived a short time later and was present for the remainder of the visit. Administrator (AD) Mark Fisk has a current Administrators certificate that expires January 27, 2026. During the inspection, LPA Haley observed all resident bedrooms. The bedrooms had all the requirements and were in compliance with regulation guidelines. All resident bathrooms were observed. Hot water temperatures were measured in between 107.6 – 109.9 degrees Fahrenheit. No hazardous items were observed in the resident bathrooms. The kitchen was clean and organized. LPA observed a perishable and nonperishable food supply in compliance with regulation guidelines. Knives and sharp objects are kept locked in a drawer near the stove. The stove was operation and all burners, and the warmer were operational. There’s a locked filing cabinet in the kitchen with resident medications and below the locked medications is a supply of nonperishable food items. A fire extinguisher was observed fully charged and mounted on the wall behind the dining table. A Carbon monoxide detector was observed mounted on the wall near the stairs and tested operational. There’s a locked office area, a staff bedroom, and a bathroom on the second level of the facility. The second level of the facility is off limits and inaccessible to residents in care. Staff and client files are locked in the office. Continued on LIC809C There’s a locked laundry room equipped with a washer, dryer, and hazardous cleaning chemicals. The garage is used for storage and remains off limits and inaccessible to residents in care. The backyard was clean and organized. Walkways are free of obstruction. During the tour of the exterior portion of the facility, LPA Haley observed a shaded patio area with a table and chairs. The side exit gate is self-latching. Smoke detectors were observed in all resident rooms, the living room, and hallways. During the inspection all smoke detectors tested operational. The last emergency drill was conducted November 18, 2024, and are conducted quarterly for staff on each shift. During the inspection, 3 resident files were reviewed, 3 resident medications were reviewed, 2 staff files were reviewed, and 2 staff members were interviewed. Deficiencies are being cited for observations made during the inspection, record review, and a Technical Advisory will be issued. An exit interview conducted, and a copy of this report was provided to Licensee/AD Mark Fisk