Facility Evaluation Report

On 10/16/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit. LPA introduce self, stated the purpose of the visit, and met with Administrator (A1) Ashley Bell. All 20 residents were present during inspection. LPA toured facility with A1.

The facility was observed to be at a comfortable temperature. The facility was observed clean, and no passageway obstructions or fire hazards were observed inside or outside. Outside of facility toured and observed to be free of debris. Adequate outside seating was observed available for residents. Last fire drill completed on 06/20/25. Fire extinguisher was observed throughout the facility with a service date of 05/05/25.

An adequate supply of perishable and non-perishable food was observed. Walk in refrigerator temperature maintained at 32 degrees F. Freezer temperature maintained at -29 degrees F. Cleaning chemicals observed stored and locked under kitchen counter and in staff bathroom. PPE supplies such as gloves and masks were observed in medication room. Medications observed kept locked in medication cart in the medication room. Medications were checked and MARs were reviewed.

Washer and dryer was located in detached garage. Paper supplies observed in detached garage. All bedrooms were observed to have required furnishings with adequate lighting and at comfortable temperature. Carbon monoxide and smoke detectors were tested and observed in each bedroom. Bathrooms observed with grabbed bars and non-skid mat. Bathrooms observed with adequate paper supplies. Toilet observed good repair and operational. Bathroom hot water temperature was tested at 117.6 degrees F in bathroom 1, 120 degrees F in bathroom 2, and 119.7 degrees F in bathroom 3.