Facility Evaluation Report

On 09/30/2025, 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 Administrator - Deanna Tyree. LPA toured facility with Assistant Administrator - Rebecca Brian.

Facility has one entrance/exit point. LPA toured facility inside and out with Assistant Administrator - Rebecca Brian. During this visit clients were away at day program. 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. 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 12/11/2024. All 6 clients bedrooms were observed to be with comfortable temperature. Water temperature measured in restroom at 112.4 Degrees F

Medications observed to be locked in a cabinet in the kitchen. LPA reviewed MAR, Medication to be administered correctly at time of inspection. Cleaning supplies were observed to be in a locked cabinet in the laundry room. An outdoor seating area was observed for residents in care. Pool area fenced, gated and locked.

LPA reviewed Staff and Resident files. Resident files observed to have update information. No deficiencies were observed. Exit interview conducted. Report was signed and copy of this report was provided for facility records.