Facility Evaluation Report

On 12/08/2025, Licensing Program Analysts (LPA) J. Duarte and S. Doucetter, arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was greeted by Staff Myya Brewster. LPA was granted entry. Staff contacted Administrator Cheryl McCraw and she arrived shortly after.

LPAs toured facility with Myya and Cheryl. The facility was observed to be at 73 degrees F, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed.

Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a temperature of 108.7 degrees F. Non-skid mat and grab bars observed in bathrooms.

Fire extinguisher was observed with a service date of 05/05/2025. The last fire drill was completed on 11/06/2025, per staff records. The facility has a pull station fire alarm. Carbon monoxide and smoke detectors were tested and observed to be operational.

A sample of resident files were reviewed and had required documents. Samples of staff files reviewed. S1 is missing health screening. Medication are kept in a locked cabinet. Sharps are also stored in a locked cabinet. Residents’ MARS and Centrally Stored were reviewed and medication log reflects medication to be administered as prescribed. First aide kit observed with all of the required items.