Facility Evaluation Report

On 04/30/25 around 10:50 AM L. Holmes, Licensing Program Analyst (LPA) arrived unannounced to conduct a required annual inspection. LPA was greeted by Care Staff (S2), met with Mavis Freeman, CEO/Administrator (ADM) about 15 minutes later, and explained the purpose of the visit.

LPA and ADM toured the facility including but not limited to the receptionist area, exercise room, and the game room that offers a WII gaming system, stationary exercise bikes, light weights and an area to relax. The conference room still serves as a retreat for clients and for staff to meet. LPA observed infection control compliancy with covered garbage cans, PPE, hand sanitizer, and linens. There is a separate room with a washer and dryer that offers an alternate space to provide bedding if isolation is needed. The facility also offers a zen room with pedicure care, a multimedia room, swings, basketball, boxing bags and a variety of board games. The facility has adequate lighting throughout. The FAME area still offers karaoke, a 360 photo carousel and provides props to dress-up to take and print photos.

Indoor and outdoor passageways were observed free of obstruction.There were no bodies of water observed. LPA observed the water at 106.1 degrees F. and room temperature at 68 degrees F. A 30-day emergency food supply of non-perishable foods, and portable gas stove remains in place. The facility has separate bathrooms for men and women with grab-bars, non-skid floors and the entire facility is wheelchair accessible. The facility has flashlights available for emergency use. First-aid kits remain complete, and smoke and carbon monoxide detectors were operational. Fire extinguishers exp:10/16/25. Emergency Disaster plans/contact information is posted throughout the facility, personal rights and hand-washing signs are posted in the facility, and the facility is using an online program for electronic files to reduce paper and waste.

Exit interview conducted and a copy of this report provided to ADM.