Routine inspection·April 22, 2026

On 4/22/26, Licensing Program Analyst (LPA) Kyle Wellington arrived unannounced to conduct an annual inspection. LPA was greeted and let into the facility by Caregiver, Cristina Agoscruz, who was informed of the purpose of the visit. Administrator (Admin), Garrett Welker, arrived shortly thereafter to the facility to meet with LPA. LPA observed two (2) staff and four (4) residents present at the facility. The census at the facility is five (5) residents with one (1) resident in the hospital. Two (2) residents are receiving hospice care. LPA received a staff and resident roster from the Caregiver. LPA toured the inside and outside of the facility with the Caregiver. LPA conducted an observation and record reviews for the inspection. Facility Overview: The facility is a one story house with six (6) resident bedrooms, one (1) staff room, two (2) resident bathrooms, one (1) staff bathroom, kitchen, dining room, family room, laundry room and attached garage. There were no pools, bodies of water or firearms at the facility. Facility has a fire clearance to serve six (6) non-ambulatory elderly residents of which one (1) may be bedridden. Facility has an approved hospice waiver for six (6) residents. Infection Control: LPA observed hand soap dispensers and hand sanitizers throughout the facility. Cleaning equipment and cleaning supplies were kept locked in the garage and available for regular facility maintenance. LPA reviewed the facility’s infection control plan which met the department’s requirements. Physical Plant: LPA observed the inside and outside of the facility to be clean, safe and well kept. The floors, windows and doors were clean and well maintained. The family room and dining room furniture was in good repair. The halls had night lights and no obstructions. The residents’ bedrooms were neat, organized and had the required bedding, furniture and lighting. Bathrooms were clean, tidy and contained soap, paper towels, grab bars and non-slip tile in the showers. The hot water temperature in the bathroom was measured at 108.2 F. Clean linens and towels were readily available in a cabinet in the hall. Laundry equipment appeared to be in good working condition. Laundry supplies were kept in a cabinet in the locked laundry room. Incontinent supplies and cleaning supplies were stored separate from the emergency food and water in the locked garage. The one (1) fire extinguisher was charged and available for use. LPA and Admin tested one (1) of the smoke and carbon monoxide detectors and found it to be operational and hard wired. Facility had a pull system fire alarm in the hall. The backyard was clean, free of hazards and contained outdoor furniture and shaded areas for the residents. Kitchen/Food Service: LPA observed the kitchen to be clean, organized, and well maintained. The kitchen had the ability to prepare and store food in a safe and clean environment. Kitchen appliances appeared to be in good working condition. All sharp and dangerous objects were kept in a locked drawer in the kitchen inaccessible to residents. Cleaning supplies were kept in a locked cabinet under the sink inaccessible to residents. The refrigerator/freezer was clean, stocked and at the required temperatures. Food in the refrigerator/freezer and cabinets was properly stores and not expired. The facility has at least a two day supply of perishable foods and a seven day supply of non perishable foods. The hot water temperature in the kitchen was measured at 110.4 F. Care & Supervision: LPA observed the facility had sufficient staff present to supervise the residents. Administration: LPA observed that the facility's license, Long Term Care Ombudsman information, residents' personal rights information and complaint information was posted in the hall near the front door. Liability insurance was up to date. Admin holds a current Administrator Certificate and CPR Certification. Admin has a criminal record clearance. Record Review and Resident/Staff Files: LPA compared the staff present at the facility and on the staff roster to the Guardian staff roster for criminal record clearance. LPA reviewed the records of two (2) staff files and three (3) residents’ files. The files contained all the required documentation and paperwork. The staff and residents’ files were kept in a locked closet in the kitchen inaccessible to unauthorized individuals. Health Related Services/Incidental Medical Services: LPA observed all residents’ medications were kept in a locked in a cabinet in the kitchen inaccessible to residents. LPA reviewed two (2) residents' medication to the facility’s medication log to make sure all medication was accounted for and dispensed correctly. First Aid kit contained all the required items and was kept in a locked closet in the kitchen inaccessible to residents. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan. The plan was current and up to date. Safety and fire drills have been conducted. All facility exits were clear of obstructions. No deficiencies were cited during this visit. Exit interview was conducted with the Administrator and a copy of this report was given to the Administrator.