Routine inspection·October 22, 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 Executive Director (ED) Ernest "EJ" Lewis and Maintenance Director Perry Garrett. The facility's license shows a maximum capacity of two-hundred-and-fourteen non-ambulatory residents, eight (8) of which may be bedridden. Bedridden residents may only reside in bedrooms 124-137. Additionally, the facility is approved for fifteen (15) hospice residents and does not accept Dementia residents. During today’s inspection there were eighty-nine (89) residents in care. Note, LPA did step out for lunch from 12-1pm. LPA and ED Lewis toured the interior and exterior of the facility and inspected a sample of occupied and unoccupied resident rooms. 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 in an unoccupied unit was 105.6F. 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 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 ED Lewis, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months, dated for service in September 2025. Last emergency drill conducted was on 10/3/25 for the topic of fire. The facility maintained excellent record keeping for maintenance and fire safety items. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed one (1) staff and one (1) client, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents, however LPA noted that staff training in the sampled records did not cover all required topics and a Type B citation was issued. Confidential records were stored in locked areas. During file review, LPA did also note that a bedridden resident (R1) was residing in a non-bedridden approved unit and had a Dementia diagnosis, which the facility's license does not approve. Two (2) additional type B citations were issued for the fire clearance violation and for operating beyond the conditions of their license. Three (3) deficiencies total were cited during the inspection. An exit interview was conducted with ED Lewis to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.