Routine inspection·February 10, 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 Danielle Thurman. The facility's license shows a maximum capacity of six (6) non-ambulatory residents age sixty (60) or above. The facility is approved for one (1) bedridden resident, who must reside in room number three (3). During today’s inspection there were six (6) residents in care. LPA and caregiver Dillan Ena toured the interior and exterior of the facility and inspected each room. Assistant Administrator Meredith Pritchard-Malo arrived later during the visit. 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: Bathroom sink 1 read at 105F, bathroom 2 read at 114F, and the kitchen tap read at 111F. 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. [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 caregiver Dillan, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed two (2) staff and zero (0) clients, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents, aside from staff training of fire drills. Confidential records were stored in locked areas. A deficiency was cited during the inspection for the lack of fire drills conducted as required. An exit interview was conducted with Assistant Administrator Pritchard-Malo to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Their signature below confirms receipt of these documents.