Facility Evaluation Report

On April 24, 2025, Licensing Program Analyst (LPA) Kayla Adkison, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Resident Service Director (RSD), Pomali Thitphaneth, and explained the purpose of the visit. Administrator, Cliff Keene, arrived approximately 30 minutes later and joined the inspection

LPA and RSD toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas for dinning and activities, four (4) resident bedrooms, four (4) resident restrooms, and the courtyard. LPA observed the facility to be clean, in good repair and odor-free. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA observed each resident bedroom to have the required furnishings. LPA observed calendar for monthly activities at the facility, and a daily posting of activities to help engage the residents. LPA observed the activities director conducting activities with several residents in the courtyard. LPA observed the kitchen to be clean and well stocked with a variety of food for residents. LPA observed a clear list of residents with restricted diets. Facility has a 2-day perishable and a 7-day non-perishable amount of food.

LPA observed a locked closet which contained toxic chemical storage. The door to the laundry room is locked. LPA observed the medication to be locked and inaccessible to residents.

LPA observed fire extinguishers which were last serviced in February 2025. The facility was in the middle of an active fire drill.

LPA reviewed a total of six (5) residents' files and five (5) staff files which contained all of the required documentation.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report left at the facility.