Facility Evaluation Report

On 01/20/2026 at 8:30AM, Licensing Program Analyst (LPA) Andrew Christy arrived unannounced to conduct the 1-Year Annual Required inspection. LPA met with DSP, Irish Arenas, and explained the purpose of the visit. Administrator Debbie arrived at 10:00AM The facility currently houses two (2) residents with a max capacity of four (4) residents.

LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. No bodies of water were observed. A comfortable indoor temperature is maintained at 69.0 degrees Fahrenheit. The hot water temperature in the residents’ shared bathroom was measured at 107.4 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 07/11/2025.

At 9:45AM, LPA reviewed two (2) resident files and four (4) staff files, all found to be complete. The emergency disaster plan was last reviewed 01/20/2026. Quarterly emergency drills were last conducted 09/05/2025. A review of resident medications and the Medication Administration Record (MAR) found no outstanding errors. The Resident I&P Log was reviewed and there were no outstanding errors.

No deficiencies cited during visit. Exit interview conducted and a copy of this report was provided to the administrator.