Routine inspection·October 23, 2025

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit for a required annual inspection . The LPA was greeted by Administrator Elizabeth Mahan, notified them of the purpose for the visit and was allowed to enter the facility to conduct the inspection. Facility Overview: The facility is a single- story building with 17 residents' bedrooms, 19 bathrooms, a dinning room, a recreation room, a medication room, a kitchen, a laundry room, an office, and an outdoor area. There is no gated pool and there are no firearms on the premises. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department's requirements. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in the kitchen area and inaccessible to residents in care. The carbon monoxide detectors were operable. LPA observed fire extinguisher to be in compliance with the department's requirements and with an expiration date of 08-04-2026. The water temperature was tested at 130.4 F. Citation with be issued Continued 809-C...... Care & Supervision/Administration: Adequate staff were present to supervise residents during the visit. The Administrator holds a current administrator’s certificate with the expiration date of 02-28-26 and CPR certification with the expiration date of 08-01-26. Record Review and Resident/Staff Files: LPA reviewed files for 4 staff members, confirming criminal clearance, updated training, and health screening. 3 residents' files were reviewed and contained all the required documentation. LPA observed first kit to be available for the residents in care. The residents and staff files were kept locked and inaccessible to unauthorized individuals. Health-Related Services/Incidental Medical Services: All residents' medications were securely locked in a the medication room. LPA reviewed medications for 3 residents and found discrepancies with records and the medication being administered. Citation will be issued. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last emergency drill conducted on 10-05-2025, which met the department's requirements. All facility exits were clear of obstructions. Deficiencies were cited during the visit. An exit interview was conducted, during which this report, the 809 D and the appeal rights were reviewed, and a copy was provided to Administrator Elizabeth Mahan