Facility Evaluation Report

On 06/19/2025 at 1:00PM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger and A. Christy arrived unannounced to do an annual inspection. LPAs met with Administrator Mary Ann Lebya and explained the purpose of the visit.

LPAs inspected the facility inside and out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPAs inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade. The facility has a mitigation plan. Fire extinguishers were observed fully charge and tags showed serviced 01/06/2025. Water temperature measured in resident's room to be 113.5 Degrees F. Fire Drills are conducted monthly and last one was conducted in May 2025.

At 2:00PM LPA reviewed 5 residents records and reviewed 3 staff records. 3 of 3 staff were fingerprint cleared and associated to the facility. Emergency Disaster Plan last reviewed this June. Liability insurance is updated for this year.

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