Routine inspection·September 18, 2025

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 non-ambulatory residents, one of which may be bedridden. As of today, the facility has five residents admitted to the facility. Four residents were present during the visit. There’s a total of 4 bedrooms, 3 of which are for residents. One bedroom is being used as an office space. There are two restrooms, one for residents and one for staff. The staff restroom is locked, but can be used by residents. There’s a living room space, a dining space 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, sink, and tub/shower. Grab bars are tightly secured to the wall. Hot water measured at 113.7 degrees F. Kitchen: 4 of 4 burners were operational on the gas stove. Sharps are kept locked in the medication cabinet next to the refrigerator. Cleaning solutions are stored in a locked cabinet below the sink. Food Service: A supply of perishable and non-perishable food items that meet regulation requirements was observed. Client & Staff Files : Resident and staff files stored in a locked cabinet in the staff office room. File Review: 3 of 5 resident files were reviewed during the visit, and 3 staff files were reviewed. of 5 resident medications were reviewed during the visit. Continued on LIC809C Medications/First-Aid Kit: Resident medications are stored in a locked medication cabinet in the kitchen. Medication Review: 3 of 5 resident medications were reviewed during the visit. Linens & Hygiene Supplies: Hygiene items were observed in the main hallway cabinet with a supply of clean linens. An additional linen supply was observed in the staff office. Garage Area: The garage is organized and used mainly as a storage area. A washer and dryer was observed. An additional refrigerator was observed. Miscellaneous facility items were observed: matts, walker, and incontinent care supplies to name a few of the items observed. An emergency supply of water and emergency food was observed. Backyard/Exterior: The backyard is organized. Walkways are free of obstruction. A table with some chairs was observed under a shaded patio area. A storage shed used to store facility items like walkers, and wheelchairs was observed. Bodies of Water: None. Smoke/Carbon Monoxide Detectors: Smoke and carbon monoxide detectors tested operational. Fire Extinguisher: Fire extinguisher was observed mounted on a wall in the main hallway and inside the garage near the door to enter the kitchen area. An emergency evacuation drill: June 30, 2025. Evacuation drills are conducted quarterly. Emergency Phone Numbers, House Rules, Exit Plan & Menu: Several facility postings are posted, and available for review on the main postings wall as soon as you enter the facility. Additional Comments: Licensing fees are past due. LPA called the licensee during the inspection in regards to the licensing fees. LPA was expecting a call back before the end of the visit. LPA will follow up with licensee regarding the annual fees. During the visit, 3 of 5 resident files were reviewed, and medications were reviewed for 3 of 6 residents. 3 staff files were reviewed during the visit. Facility telephone number and the additional contact information was confirmed during the visit No deficiencies are being cited during today’s visit. An exit interview conducted, and a copy of the report was provided.