Facility Evaluation Report

On 11/19/25, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual required inspection. LPA arrived, introduced self, and stated purpose of visit. LPA allowed entrance by Lead Staff. House Manager contacted by telephone, and arrived a short time later to meet with LPA.

Facility is a 4 bedroom 2 1/2 bathroom home. Currently, there are three (3) resident in placement, all residents have private bedrooms and all residents were present at time of inspection. LPA observed facility to be clean, odor free, and maintained at a comfortable temperature. Facility tour conducted, all bedrooms, observed to have required furnishings available. LPA observed panel in Resident 1 (R1) bedroom to be in need of repair and/or replacement. Resident bathrooms toured, LPA observed shower chairs, grab bars, and non-skid mats. Water temperature measured at 116 degrees F. LPA observed bathroom near kitchen, to have water damage at entrance to shower area. Bathroom near living room is missing floor tiles and in need of repair. Dining room area and living room area have adequate seating available for residents in care. LPA observed panel in living room to be in need of repair and/or replacement. Doors and framing around doors within the facility in need of repair and/or painting from wheelchair damage. Kitchen toured, facility observed to have a 2-day supply of perishable and a 7-day supply of non-perishable available. Kitchen knives observed to be locked and secured in hall closet. Medications observed to be locked and secured in medication cart.

Smoke detector and carbon monoxide detector observed operational at time of inspection. Fire extinguisher has a service date of 9/19/25. . Last fire drill conducted on 10/27/25 according to facility records.

Outside toured. All exits open free of obstruction. No hazards observed.

Deficiencies cited on the attached 809D. Exit interview conducted and a copy of report provided to House Manager for facility records.