Facility Evaluation Report

On 10/2/25 at 10:00 am Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection LPA was greeted by Royal Timmons (S1). LPA introduced self, stated the purpose of the visit Licensee (L1) Linda Burrus was not present during inspection. LPA was granted entry. No residents were present during inspection because of attendance at day program.

LPA toured facility with S1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Freezer temperature was maintained at -5 degrees F and refrigerator temperature was maintained at 35 degrees F. Fire extinguisher was observed with a purchase date of: 12/19/24. Fire drill last completed on 9/3/25. Washer and dryer observed operational during visit. Carbon monoxide and smoke detectors were tested and observed to be operational. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a temperature range of 105.6 and 107 degrees F in 2 bathrooms. Outside of facility toured. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for residents. A sample of medications were checked and observed kept locked in the locked cabinet. Residents’ MARS was reviewed. A sample of medications were checked and observed kept locked in cabinet. First aide kit observed with all of the required items.

All residents and samples of staff files reviewed and did not maintain some of the required documents. TSP services recommended and accepted per Licensee.

Operational Requirements - Type B: 80026(h)(1) - 1 out of 3 Residents is missing the Safeguard for Property Values form in Client File.

Personnel Records - Training - Type B: 80066(e) - 1 out of 2 staff is missing the LIC-501.

Incidental Medical Services - Type B: 80092.1(l) - 1 out of 2 staff is missing documentation or certificate of completed medication training.