Routine inspection·June 3, 2026

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit. The LPA met with Administrator Jennifer Shaffer and explained the reason for the visit. RECORD REVIEW: Starting at 12:50 p.m., the LPA conducted a file review for all four (4) residents and staff regularly scheduled and observed the following: Staff have current first aid and training documentation showing required training completed. Resident records were reviewed for, but not limited to: care plans, medical records, admissions agreement, consent forms. All files were in order. Administrator’s Certificate expires on 05/25/2027. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility’s infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. The LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually as required. The last fire/earthquake drill was conducted on 04/02/2026. Beginning at 02:08 p.m., the LPA along with the Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards. The following was observed: BEDROOMS: The facility is a single-story residential home with five (5) bedrooms, four (4) for resident use and one (1) for staff use. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and slip resistant surfaces. Hot water measured within required range. Report Continued on LIC-809-C OUTDOOR SPACE: The LPA observed the back patio which has a covered outdoor area for resident use. There is a gate on the side of the house designated for an emergency exit. The garage is attached and remains inaccessible to residents. Laundry units are located inside the garage. Cleaning solutions are located inside the garage. There are no bodies of water on the premises. COMMON AREAS : The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguishers to be fully charged and last serviced on 04/23/2026. At 03:15 p.m., fire alarms/carbon monoxide detectors and fire door were tested and functioned properly. There is a working telephone on premises. The LPA observed additional clean linens and towels in the hallway closets. KITCHEN: The LPA observed the kitchen and dining area. Knives are stored locked and inaccessible inside a kitchen cabinet. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food and emergency water. MEDICATION REVIEW: At 02:32 p.m., the LPA conducted a review of medication and medication documentation with the Administrator for two (2) residents. Medications are centrally stored and inaccessible inside a locked cabinet near the kitchen area. First aid kits are located throughout the facility. No medication discrepancies were observed. During the time of the visit, the LPA conducted interviews with two (2) residents and one (1) staff. No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.