Routine inspection·September 8, 2025

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Administrator John "Stuart" Neave. The facility is licensed for a maximum capacity of 6 non-ambulatory residents, 1 of which may be bedridden in rooms 1, 5, or 6. The facility has a waiver for 3 hospice residents. During today’s visit, the facility had a census of 5 non-ambulatory residents. The Administrator for the facility is John "Stuart" Neave and their certificate was valid and current. During today’s visit, LPA toured the facility and inspected resident rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. LPA did not observe any aspects of delayed egress or secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 111.0 and 114.1 degrees Fahrenheit in bathrooms for resident use. The facility’s internal temperature was measured at 73 and 76 degrees Fahrenheit across the facility. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to "Stuart" Neave, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and labelled. LPA observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerators were kept at 40 and 45 degrees Fahrenheit, and the facility freezers were kept at 0 and -10 degrees Fahrenheit. Continued on LIC809-C page… LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate. LPA reviewed multiple resident and staff records. LPA provided Administrator with consultation and guidance regarding the regulation changes that became effective 1/1/2025. An LIC9102TA Technical Advisory regarding record keeping was provided. No deficiencies were cited on today’s date. An exit interview was conducted with Administrator John "Stuart" Neave, whose signature below confirms receipt of a copy of this report, the LIC9102TA, and the Licensee Appeal Rights (LIC9058 3/22).