Routine inspection·November 17, 2025

Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Licensee/Administrator, Kelly Evans and introduced self and stated purpose of the visit. LPA was informed that there is 1 resident home and 1 resident out in the community. The facility has 4 bedrooms, 2 bathrooms, kitchen, 2 dining areas, living room, family room with an inaccessible fireplace, office room, laundry room, backyard, and attached garage. LPA completed a walk through of facility and review of records and medication audit with Licensee, Kelly Evans. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 73 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 120 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher and first aid kit. Posters such as; the personal rights, CCL complaint poster, visiting policy, and ombudsman were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to residents. There was a designated storage space for resident/staff files. Medications was observed locked and inaccessible to residents. There is no swimming pool, bodies of water, firearms or ammunition in the facility. Food Service : Non-perishable and perishable food supply is sufficient for residents in care. Dishes, cups, and utensils were also stored properly. Yards/Outside: One shaded patio, side gate with self-latching handle on the left and right side of the house that leads into the backyard. Record Review: LPA reviewed staff and administrator file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA discovered that the administrator's certificate expired and was not been renewed. Deficiency issued. LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA discovered that the licensee did not have complete resident files for all residents. Deficiency issued. LPA discovered that the 2 resident files did not proof of TB testing. Deficiency issued. LPA discovered that a death report was not sent to the regional office for a resident's passing. Deficiency issued. Medications were audited and appeared to be managed appropriately. LPA reviewed facility's file for disaster drills, emergency disaster plan, infection control plan, and insurance policy. LPA observed that the Licensee did not have a copy of the infection control plan. Deficiency issued. LPA discovered that the licensee did not have emergency kits. Deficiency issued. LPA observed that the licensee did not have an emergency disaster plan. Deficiency issued. Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, and appeal rights were discussed and copies were provided to Licensee/Administrator, Kelly Evans.