Facility Evaluation Report

Licensing Program Analyst LPA Shawna Doucette arrived at the facility unannounced and conducted an Annual Inspection on this date. LPA was granted entry by Staff Tamesha Ortiz. Staff contacted Administrator Cheryl McCraw via telephone, who responded to the facility to assist with the visit.

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 toured, appeared clean and safe for food preparation. Food supply checked, LPA observed an adequate supply of food. Hot water measured at 108 F degrees. Facility was set at 73 F.

Resident rooms checked. Facility is in the process of adding an additional room to the facility. Facility obtained building permits. Facility will submit fire clearance request once construction is completed by 10/24/25. LPA observed an adequate supply of linen. Hot water measured at 108 F degrees.

Fire extinguisher serviced on 08/13/2025. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted 9/13/2025.

LPA reviewed staff and resident files. LPA reviewed medication. Facility had a prescription for C1 which stated it should be administered at noon. Facility staff wrote 3 PM on the label.

Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching. Facility added new turf to the yard.

An exit interview was conducted with the Administrator and a copy of this report with plans of correction and appeal rights were provided.