Facility Evaluation Report

On 4/17/25, Licensing Program Analyst (LPA) M. Medina and Licensing Program Manager (LPM) A. Walton conducted an unannounced Annual Continuation visit to facility. LPM and LPA arrived, introduced themselves, stated purpose of visit, and allowed entrance by Caregiver. Designee, Shontina Kelly, contacted by telephone and arrived a short time later to conduct facility visit.

During last facility visit, Administrator on record was not present and LPA was informed that she had been absent from facility and had moved out of state to attend school. Prior to today's inspection, LPM Walton received a Administrator packet for Rosanda Anderson that is currently under review.

Upon entry, LPA observed a pin pad on both exterior and interior of door that requires code to unlock front door. . Resident bedrooms toured, residents rooms are observed to have required furnishings, Bedroom #4 observed to have to have a pin pad on both exterior and interior of door that requires a code to unlock door. LPA was unable to open door, bedroom #4 is designated as bedridden bedroom. Resident bathroom toured, water temperature measured at 108 degrees F. Shower/Tub observed to have a non-skid mat and shower chair available. Kitchen toured, LPA observed adequate food supply for residents in care. LPA observed lock on pantry door that needs to be removed. Medication reviewed and observed to be administered as prescribed.

During facility tour, LPA asked designee how residents exited facility, designee stated that they just had to push "letter C" on pin pad and pull door open. R1 was unable to open door when asked by LPA.