Routine inspection·October 14, 2025

Licensing Program Analyst (LPA) Graham Gunby arrived unannounced at the facility to conduct a required annual inspection utilizing the care tool. LPA contacted Administrator who informed LPA he was unavailable for illness, but the LPA can meet with Caregiver, Mary Thenu, for assistance. Today's census is five residents in care with two residents on hospice services. Facility is licensed for six non-ambulatory of which one can be bedridden, hospice waiver of three. LPA observed two residents in the common area, three residents in their room. During today's inspection, LPA and Caregiver conducted a tour of the interior and exterior of the facility to ensure the health and safety of residents in care. LPA and Caregiver conducted a tour of bathroom, laundry, kitchen, resident bedrooms, office, backyard and the common areas. LPA observed sharps in the kitchen to be locked and secured. LPA observed medications to be organized in individual bins locked in the hallway. LPA observed toxins to be locked separately from other items. LPA inspected the pantry and observed approximately seven days of non-perishable foods. LPA observed refrigerator to contain approximately two days of perishable foods. LPA observed areas to be clean and free of obstructions. LPA reviewed 5 of 5 resident records and 3 of 3 staff records. Both resident and staff binders contained the required signed documentation. N o deficiencies cited. Exit interview conducted and a copy of report was emailed to Admin.