Facility Evaluation Report

Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct an Annual Inspection. LPA was granted entry by Licensee/Administrator Sophia Nelson.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Kitchen was clean and safe for food preparation. LPA observed an adequate supply of food. Resident rooms were clean and furnished. LPA observed an adequate supply of linen. Hot water measured at 112.6 degrees F. Facility was set at 75 F.

Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching.

Fire extinguisher serviced on 07/09/2025 Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Facility has a pull station fire alarm. Last fire drill conducted 09/01/2025 and are conducted monthly. All cleaning supplies are locked and secured in a cabinet in the garage.

LPA observed a room built in the garage which is not fire cleared.

LPA reviewed staff records, resident records and medication.

An exit interview was conducted with the Licensee/Administrator and a copy of this report with plans of correction and appeal rights were provided. Civil Penalty was issued for fire clearance.