Facility Evaluation Report

On 4/08/25, 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 self, stated purpose of visit, and allowed entrance by Caregiver. Designee, Rosanda Anderson, 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.

Resident bedrooms toured, residents rooms are observed to have required furnishings, Resident bathroom toured, water temperature measured at 119 degrees F. Shower/Tub observed to have a non-skid mat and shower chair available. Kitchen observed to have a locked wrought iron gate making kitchen inaccessible to residents. The wrought iron gate was not in place, when facility received fire clearance. LPA observed facility has a 7-day supply of non-perishable food available or a 2-day supply of perishable food available. Medication reviewed and observed that 3 out of 5 residents did not receive medications due to medication being refilled. R1 has medication listed on physician's report, care plan, and hospital discharge paperwork, R1's medication is not on hand or listed on MARS or Centrally Stored Medication. Facility is unable to provide documentation for discontinuation of R1's medication.

Staff and resident files reviewed. All staff files reviewed are missing proper documentation for training. Resident files were incomplete and did not contain Appraisal/Needs and Services Plans.