Routine inspection·January 28, 2026

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA was greeted, granted entry by staff and explained the reason for the visit. Structure: The facility is a single level structure and licensed for six residents (6 non-ambulatory) and has a hospice waiver for six. As of today, the facility has six residents admitted. All residents were present during the visit, and one left for their day program shortly after the visit began. There is a total of 4 bedrooms (3 resident & 1 staff) and 2 bathrooms areas (1 Resident & 1 Staff). There’s a living room space, a dining space, backyard and an attached garage. Bedrooms: All bedrooms have the required furnishings: bed, lamp, chair, and storage space. Bathroom(s): Bathrooms are equipped with a working toilet, wash basin, and shower. Hot water was measured in the range of 110.6 and 114.8 degrees F. Kitchen: 4 of 5 burners are operational on the gas stove. The center burner will not light unassisted. No sharps or cleaning solutions are stored in the kitchen. Food Service: A supply of perishable and non-perishable food items that meet regulation requirements was observed in the kitchen. Additional food and water was observed in the garage. Resident & Staff Files : Resident and staff files are stored in the locked filing cabinet in the kitchen. File Review: Three resident files were reviewed during the visit, and three staff files were reviewed. Medications/First-Aid Kit: Resident medications are stored in the locked medication cabinet in the kitchen. A first aid kit with all the required elements was observed in a cabinet in the kitchen above the printer. Medication Review: Three resident medications were reviewed during the visit. No discrepancies were observed. Medication is being administered as prescribed. Continued on LIC809C Linens & Hygiene Supplies: Additional linens and incontinent care items were observed in the main hallway closets. Resident hygiene caddy’s are stored in the locked staff bedroom. Garage Area: The garage is organized and walkways are free of obstruction. There’s a laundry area with a washer and dryer. Soaps and cleaning solutions are stored in a cabinet. There’s an additional fire extinguisher mounted in the garage by the door. A disaster supply bag and additional first aid kit was observed prepared and ready to go in the event of an emergency. Arts and craft items were observed. Backyard/Exterior: The backyard has a shaded patio area with a table, chairs, and a mounted television. Two locked storage sheds were observed. One storage shed is used for additional nonperishable food storage. The second locked storage shed is used to store miscellaneous resident care items, and additional incontinent care supplies. Incontinent care items and a wheelchair was observed. Administrator was advised to remove any and all items from the garden that may attract rodents and/or insects. Bodies of Water: None. Smoke/Carbon Monoxide Detectors: Smoke and carbon monoxide detectors tested operational. Fire Extinguisher: Fire extinguisher was observed mounted in the main hallway and in the garage. An emergency drill: An emergency drill was conducted January 6, 2026. Disaster drills are conducted quarterly. Emergency Phone Numbers, House Rules, Exit Plan & Menu: Facility postings are posted are available for review on the main postings board in the main hallway area. Additional Comments: Licensing fees are current. Updated facility contact information (mobile number and email) was provided and the profile will be updated Three staff interviews were conducted, one resident interview was conducted and one resident interview was attempted. Deficiencies observed during annual inspection will be cited. An exit interview conducted, and a copy of the report, technical advisory and appeal rights were provided.