Routine inspection·October 14, 2025

On October 14, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry into the facility by care giving staff after explaining the purpose for the visit. Administrator Cherie Wood (AD) was notified via telephone but was not able to assist with today's inspection. LPA observed that Cherie Wood has a valid Administrator certificate which expires on August 19, 2027. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents, of which four may be bedridden, and has a hospice waiver for four. The facility is a single story home with six private resident bedrooms, one staff bedroom, eight bathrooms, a living room, a dining room, a family room, a kitchen, and an attached two car garage. LPA, accompanied by a care giving staff, conducted a tour of the interior portions of the facility. On today's visit, LPA observed six resident in care and two care giving staff present. LPA observed residents watching TV in the family room. LPA observed the See Something, Say Something poster, (PUB 475) mounted on the wall by the entryway of the facility. LPA inspected all six resident bedrooms and observed them to be free of hazards. LPA observed resident bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA observed additional linens to be stored in a hallway closet. LPA inspected the resident bathrooms and observed them to be clean. Bathrooms were equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 111.2 to 111.9 degrees Fahrenheit. LPA observed the staff bedroom to be kept locked and inaccessible to residents in care. LPA observed the kitchen has a two day perishable and a seven day non-perishable food supply on hand. LPA observed kitchen appliances to be clean and operational. CONTINUED ON LIC809-C LPA observed the four burner gas stove lights unassisted. LPA observed kitchen knives and sharps to be stored in a locked kitchen cabinet. LPA observed fire extinguishers to be mounted on the wall in the kitchen and it was observed to be charged and purchased on May 12, 2025. LPA tested the individual smoke detectors/carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on July 25, 2025. LPA observed the centrally stored medication to be kept in a locked kitchen cabinet. LPA observed the facility has a First Aid Kit stored in the kitchen and it had all the required components. LPA observed the facility has a three day emergency food and water supply stored in the kitchen pantry. LPA observed the door leading to the attached two car garage to be kept locked and inaccessible to residents in care. LPA observed the two car garage to be used for storage and laundry. LPA observed chemicals and toxins to be stored in a locked cabinet in the garage. LPA, accompanied by a care giving staff, conducted a tour of the exterior portion of the facility. The exterior portion was observed to be free of hazards and obstructions. LPA observed a shaded outdoor seating area with furniture for resident use. LPA observed the perimeter gates of the facility to be self latching and can be opened in an evacuation. There are no bodies of water on the premises. LPA reviewed all six resident files. LPA observed that the Reappraisals on file for Resident #4 (R4) and Resident #5 (R5) were outdated. LPA reviewed the residents' medication and medication administration records. LPA reviewed four staff files. All staff are background cleared and associated to the facility. Based on the observations made during today's visit, a deficiency is being cited on the attached LIC809-D. An exit interview was conducted with an authorized facility representative. A copy of the report and Appeal Rights were provided.