Facility Evaluation Report

On 12/08/2025 at 11:15AM, Licensing Program Analysts (LPAs) Andrew Christy and David Doidge arrived unannounced to conduct the 1-Year Annual Required inspection. LPA met with Lead Staff Alexandria Jackson, and explained the purpose of the visit. Administrator Denise Mansfield arrived at XXX. The facility currently houses three (3) residents with a max capacity of four (4) residents.

LPAs 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 70.0 degrees Fahrenheit. The hot water temperature in the residents’ shared bathroom was measured at 105.0 degrees Fahrenheit. LPAs 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 05/08/2025.

At 12:45PM, LPA reviewed three (3) resident files and five (5) staff files, all found to be complete. The emergency disaster plan was last reviewed 12/08/2025. Quarterly emergency drills were last conducted 11/10/2025. A review of resident medications and the Medication Administration Record (MAR) found no outstanding errors. Resident P&I 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.