Routine inspection·March 2, 2026

On 3/2/26, Licensing Program Analysts (LPAs) Kyle Wellington and Janette Romero made an unannounced visit to the facility to conduct an annual inspection. LPAs met with the Administrator, Mark Melton, who was informed of the purpose of the visit. LPAs observed 2 (two) staff and six (6) residents present at the facility. The census at the facility is six (6) residents with one (1) of the residents receiving hospice care. LPAs received a LIC 9020 from the Admin. LPAs toured the inside and outside of the facility with the Admin. LPAs conducted an observation, interviews and record review at the facility for the inspection. Facility Overview: The facility is a one story house with six (6) resident bedrooms, three (3) bathrooms, kitchen, family room, dining room, laundry room and attached garage. There are no pools, bodies of water or firearms at the facility. The facility has a fire clearance to serve five (5) non ambulatory and one (1) ambulatory residents. The facility has a hospice waiver for four (4) residents. Infection Control: LPAs observed soap dispensers in the bathrooms and hand sanitizers in the facility. Cleaning supplies were locked in the garage and available for regular facility maintenance. LPAs reviewed the facility’s infection control plan which met the department’s requirements. Physical Plant: LPAs 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 living room and dining room furniture was in good repair. The halls had night lights and were free of obstruction. The residents’ bedrooms were neat, organized and had the required bedding, furniture and lighting. Bathrooms were clean, tidy and contained handrails and non-slip mats in the shower. The hot water temperature in the bathroom was measured at 112 F. Clean linens and towels were available in a hall closet. Laundry equipment appeared in good working condition. The one (1) fire extinguisher was charged and available for use. Admin tested one (1) of the smoke and carbon monoxide detectors and LPAs found them to be hard wired and operational. The backyard was clean, free of hazards and contained outdoor furniture & shaded area for the residents. Kitchen/Food Service: LPAs 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 equipment appeared to be in good working condition. Dishes, containers, pot/pans and silverware appeared clean and in good condition. All sharp and dangerous objects were kept in a locked drawer inaccessible to residents. Cleaning supplies were kept in a cabinet in the garage inaccessible to residents. The refrigerator/freezer was clean, stocked and at the required temperatures. Food in the refrigerator/freezer and cabinets/pantry/garage were stored properly and not expired. The facility has at least a two day supply of perishable foods and a seven day supply of non perishable foods. Care & Supervision: LPAs observed the facility had sufficient staff present to supervise the residents. Administration: LPAs observed personal rights information, facility sketch, emergency phone numbers, Ombudsman information and phone numbers and complaint procedures were posted near the front door. Admin holds a current Administrator Certificate and a current CPR Certification. Admin has a criminal record clearance. Record Review and Resident/Staff Files: LPAs compared the staff present at the facility to the Guardian staff roster for criminal record clearance. LPAs reviewed the records of two (2) staff files and two (2) residents’ files. The files contained all the required documentation and paperwork. The staff and residents’ files were kept in a locked closet in the hall inaccessible to unauthorized individuals. Health Related Services/Incidental Medical Services: LPAs observed all residents’ medications were locked in a closet in the hall inaccessible to residents. No medication was stored in a refrigerator with food items. LPA reviewed the facility’s medication administration record (MAR) 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 hall. Disaster Preparedness: LPAs reviewed the facility’s emergency and disaster plan. The plan was current and up to date. Safety and fire drills are conducted every three (3) months with the last drill occurring in 2/26. LPAs observed all facility exits were clear of obstructions and had the required signage. 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.