Facility Evaluation Report

On 2/18/2025 at 10:00AM, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced 1-Year Required inspection. LPA met with Sarah Horny, Caregiver, and explained the purpose of the visit. LPA spoke to Administrator Shirley Marshall currently holds a certificate (#6005261740) that expired on 06/26/2025. The facility’s fire clearance was approved for sixteen (16) non-ambulatory residents.

LPA toured the facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area, and side yard. The facility consists of five (8) room total and two (3) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 68 Degree F.. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 109.9 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 02/29/2024. Emergency Disaster Plan was updated on 2/1/2025 and posted. First aid kit was observed to be complete. Facility liability insurance policy term effective date: 6/13/2024 to 6/13/2025. Fire drill was conducted on 2/3/25.

Staff files was incomplete and two (2) of the (5) staff files are missing CPR and education/training which is considered incomplete.