Facility Evaluation Report

On 11/13/2025, Licensing Program Analyst (LPA) M. Vega arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by facility Staff 1 (S1). (AD) Shay Ayers was notified of Licensing visit over the phone and was able to attend the visit.

Facility has one entrance/exit point. LPA toured facility with Administrator inside and out. Facility pool serviced weekly. LPA observed pool in the back yard, fenced and the gate to the pool was locked.

The facility was observed to be at a comfortable temperature, of 75 degrees F. Facility is free of debris, in good repair, and no passageway obstructions or fire hazards were observed. Common areas were properly furnished and well-lit throughout. LPA observed residents in their rooms resting, one resident was in the living room area. Department phone number and infection prevention information signs were posted thought the facility.

Inspecting kitchen LPA observed the required 7-day supply of non-perishable food and 2-day supply of fresh perishables to be properly stored. An emergency disaster supply was observed.

Fire extinguisher was observed with a service date of 7/22/2025. All 5 residents’ bedrooms were observed to be with comfortable temperature.

Medications observed to be locked in a cabinet in the kitchen/hallway area. LPA reviewed medication records and there were no deficiencies at the time of inspection. Cleaning supplies were observed to be in a locked cabinet under the kitchen sink and in the laundry room. An outdoor seating area was observed for residents in care.