Facility Evaluation Report

On 05/06/25 around 10:15 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a required Annual Inspection. LPA was greeted by one Care Staff upon entry and explained the purpose of the visit; Nalini Bhutani, Co-Administrator (ADM) arrived about 10 minutes later. The facility’s fire clearance was approved for thirteen (13) non-ambulatory residents; hospice waivers for four (4).

LPA requested the resident roster, staff roster, three (3) staff files, five (5) resident files. LPA observed a visitor sign-in log at the entry. Emergency Disaster Plan is posted. LPA and ADM toured the facility, including but not limited to bedrooms, two (2) bathrooms (BA), kitchen, common area, front yard and backyard. All indoor passageways were free of obstruction. There were not any bodies of water present. Residents were lounging and watching television, one (1) went on a walk, the others were either sleeping, or engaged in something else. A comfortable temperature for residents was maintained at 72 degrees Fahrenheit (F), and the water temperature measured at 129.6 (F) in BA #1 and 118.2 in BA #2. LPA observed lighting in all rooms to be adequate for the comfort and safety of all the residents. The bathrooms were safe, sanitary and in operating condition. Hand washing posters, paper towels, and soap observed at all hand washing stations. Linen and hygiene supplies were available for all residents. PPE and paper goods remain sufficient. There is a minimum supply of 2-day perishables and 7-days of non-perishable foods.