Routine inspection·November 18, 2025

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to caregiver Aster Bezabih. Administrator Todd Brooks arrived later during the visit. The facility's license shows a maximum capacity of six (6) non-ambulatory residents, one (1) of which may be bedridden. Bedridden resident may only reside in room #1. Additionally the facility is approved for a hospice waiver for two (2). During today’s inspection there were six (6) residents in care. LPA and Administrator Brooks toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: kitchen sink read at 105.9F. LPA examined the tankless water heater system and observed it to be set at 120F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. Knives were locked an inaccessible to residents in care. [Continued on LIC 809-C] [Continued from LIC 809] No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Administrator Brooks, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Last staff emergency drill conducted was on 6/27/25 for the topic of fire. Fire extinguisher was noted to have been serviced October 7th, 2024. A Type B citation was issued for failure to ensure the extinguisher was serviced or purchased annually. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. When touring the backyard, Administrator Brooks explained that the patio furniture had recently been thrown out do do weather damage. The facility does have available outdoor seating in storage as well as a sister facility next door with extra furniture should it be requested by residents. LPA interviewed one (1) staff and three (3) clients, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents. One (1) staff file reviewed by LPA was unavailable and LPA was informed it was off-site due to being updated. Licensee will follow-up with submitting requested file to LPA once received. Confidential records were stored in locked areas. One deficiency was cited during the inspection for the outdated servicing of the fire extinguisher. An exit interview was conducted with Administrator Brooks to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.