Routine inspection·April 13, 2026

On 04/13/2026, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA was greeted and granted entry by Volunteer 1 (V1) who was informed of the purpose of the visit. Licensee Tyla Kincherlow was present in the facility and also informed of the purpose of the visit. LPA toured the facility with Licensee Kincherlow, conducted interviews, and reviewed records. LPA observed the facility is made up of a one-story home with four (4) resident bedrooms, two (2) bathrooms, a kitchen, dining area, living room, laundry room, and attached garage. Resident bedrooms had the required bedding, furniture, and lighting. Bathroom showers were equipped with grab bars and shower chairs. No bodies of water were observed on the premises. Indoor and outdoor pathways were free of obstruction. The facility met requirements for a two-day supply of perishable foods and seven-day supply of non-perishable foods. Knives and medications are secured in a locked cabinet. LPA observed a hallway closet with additional bath towels, bedding and linens. Licensee tested one (1) of the smoke alarms/carbon monoxide detectors and LPA heard it to be operational. LPA also observed a charged fire extinguisher mounted near the kitchen last serviced on 06/10/2025. LPA conducted a record review which noted the facility's certificate of liability insurance expires on 07/29/2026 and licensee's administrator certificate expires on 09/21/2027. LPA reviewed the facility's Emergency Disaster Drill noting their last emergency drill was conducted on 03/08/2026. Resident files reviewed had updated physician's reports and signed admission agreements. V1 has a valid CPR/first aid certification on file. The facility has an approved fire clearance to serve five (5) non-ambulatory elderly residents, of which one (1) may be bedridden. The facility also has an approved hospice waiver for four (4) residents and LPA was informed only one (1) resident is currently receiving hospice services. Departmental records show the facility is pending approval of a capacity increase request. During today's visit, LPA observed six (6) residents present in the facility. Licensee reported on approximately February 21, 2026, the fire department inspected the facility for the capacity increase request and verbally approved her to house six (6) non-ambulatory elderly residents of which one (1) may be bedridden. However, Community Care Licensing has not received an approved or denied fire clearance regarding the capacity increase request. As a result, the facility is operating over their approved capacity. LPA reviewed a copy of the facility's sketch received by the Department on 02/05/2026. LPA toured the room currently shared by Resident 1 (R1) and Resident 2 (R2) and observed a mattress in what appeared to be a walk-in closet. Inside the facility, this room is labeled as Room 4, but the facility sketch lists this room as, Bedroom 1 designated for staff. Licensee reported she placed the mattress in the walk-in closet and sleeps there as of approximately two months ago. Licensee will contact with the fire department and inquire whether a new fire clearance inspection is warranted due to the staff room being changed to a resident room. LPA also conducted an interview with V1 and determined they exceed the requirements to be exempt from obtaining a criminal record clearance. Departmental records show V1 has a criminal record clearance but is not associated with the facility. V1 reported volunteering in the facility providing care and supervision to the residents for five (5) hours a day for the past five (5) days. LPA also reviewed Resident 3's (R3's) admission agreement dated 05/23/2023 and found that the facility's visiting policy listed requests visitors to provide a 30 minute notice before arrival and restricts the visitation duration to 1-2 hours depending on whether the bedroom was shared. Licensee reported staff have not restricted R3's visits despite this being documented in their admission agreement. The facility will receive a technical violation regarding this. The facility will be cited and civil penalties will be assessed for the deficiencies noted during today's visit. Licensee was offered a referral to the Department's Technical Support Program which they accepted. An exit interview was conducted and a copy of this report, Confidential Names list (LIC 811), LIC 809-D, LIC 421BG, and Appeal Rights were reviewed and provided to Licensee Kincherlow. Note - LPA was off site from approximately 12:50 p.m. to 3:30 p.m.