Routine inspection·November 13, 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 zero residents admitted to the facility, and has not had any residents admitted to the facility since being licensed. There’s a total of three bedrooms and two bathrooms. There’s a living room space, a dining space, backyard, and an attached garage. Bedrooms: All bedrooms have the required furnishings: bed, lamp, and storage space. Bathroom(s): Bathrooms are equipped with a working toilet, wash basin, and shower. No chemicals observed in the bathroom. Kitchen: 4 of 4 burners and the warmer are operational on the gas stove. Sharps are kept locked in a cabinet near the sink. Cleaning chemicals are stored in a cabinet directly below the sink. Food Service: The facility is currently empty. LPA did observed a supply of nonperishable food items in the kitchen the Licensee/Administrator says is a part of the emergency food supply. Resident & Staff Files : Resident and staff files stored in the locked closet next to the front door. File Review: N/A Medications/First-Aid Kit: Client medications will be stored in the locked room (former laundry room) inside a locked cabinet. Medication Review: N/A Continued on LIC809C Linens & Hygiene Supplies: An additional supply of linens was observed in the main hallway closet. Garage Area: The is not being used at all. LPA observed a car in the garage and other miscellaneous items that belong to the licensee/administrator. The attached garage is locked and remains off limits to residents. Backyard/Exterior: The backyard is equipped with a shaded patio with a table and chairs. Licensee/Administrator was advised to make the side exit gat self-closing. Bodies of Water: There’s a pool surrounded by a fence that measures five feet. Licensee/Administrator was advised to make sure the pool gate is self-closing. Smoke/Carbon Monoxide Detectors: Smoke and carbon monoxide detectors tested operational. Fire Extinguisher: Fire extinguisher is mounted on the wall near the sliding door that leads to the backyard. An emergency evacuation drill: has not been conducted since there is no staff and no residents. Emergency Phone Numbers, House Rules, Exit Plan & Menu: Several facility postings are posted are available for review on the main postings board as soon as you enter the facility. Additional Comments: Licensing fees are current. The interior and exterior areas of the facility are being maintained. The facility has running water and electricity. There are no smells or odors present during the inspection. LPA Haley provided Licensee/Administrator Bui some guidance on staff and resident files, hot water temperature, facility telephone, and emergency evacuation drills. Licensee/Administrator Bui understands this guidance given and understands the importance of keeping LPA Haley and the department informed with the status of the facility. Licensee Bui will inform LPA Haley once there are plans to admit a resident prior to the resident’s admission. No deficiencies are being cited during today’s visit. An exit interview conducted, and a copy of the report was provided.