Routine inspection·March 4, 2026

Licensing Program Analyst (LPA) De Leon conducted a 1 year Annual visit to the facility above. LPA met with Back up Administrator Jessica Bailey and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, and hand soap. The facility has EPA approved disinfectant spray and cleaners. The facility has a 30-day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). Physical Plant & Environmental Safety: The fire extinguisher was last charged and inspected on May 20, 2025. The facility has 6 resident bedrooms with bathrooms and 1 common area restroom. LPA was authorized to enter and inspect facility. The facility has dual hard wired smoke and carbon monoxide detectors. The facility has a sprinkler system. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats or textured bottoms. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care land are locked in the laundry room. The facility has sufficient space inside and outside for activities and visiting. The facility has a back patio and front patio for client use with plenty of shade. The facility has telephone and internet service for resident use. Continued 809-C Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on April 29, 2026. The facility is approved for a capacity of 6. The fire clearance is granted for 6 non-Ambulatory, 6 of which may be bedridden. Hospice is approved for 4. Staffing: The facility currently employes 9 staff, and 2 Administrators. Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, and Fingerprint clearance and exemptions requirements. Administrator Certificate expires 5/10/2026. Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours completed from 04/2025-03/2026. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for signed Admission Agreements, Safeguard for property and valuables, LIC. 602A Physicians report, Appraisals Needs and Services Plan, and Emergency/ID forms. Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables and plenty extra, to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies. Incidental Medical Services: Facility provides assistance in arranging transportation to medical and dental appointments when needed. Residents have on-call doctor that visits facility. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed residents’ medications, no labels were altered, no medications were expired and all medications were kept in their original containers. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. (continued on 809-C) Residents with Special Health Needs: The facility does accept dementia residents in care. The facility currently has residents receiving Home Health services and hospice services, plan are up to date and kept on file. Oxygen sign is posted at front entry. Exit interview conducted, copy of report printed for Administrator