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 107.6.1 degrees F. Facility was set at 77 F.

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 09/01/2023. All cleaning supplies are locked and secured in a cabinet in the garage.

LPA reviewed staff records, resident records and medication.

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

LPA observed a room that was built in the garage that has not been fire cleared. LPA did not observe the room on the fire sketch.

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