Facility Evaluation Report

On 04/22/26 Licensing Program Analyst arrived at the facility to complete an unannounced annual visit. LPA met with Direct Support Professional, Shanita Richmond, explained reason for visit and was permitted entry into the facility. Licensee was contacted an arrived a short time later. LPA completed a tour of the facility inside and out. A health and safety check was completed on residents in care. 1 resident was present during visit.

Pathways and doors were clear and free from obstruction. Facility was without odor. Common areas were adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. Fire extinguisher last serviced 10/17/25. Last fire drill on conducted on 03/17/26. Resident rooms observed to have the required furnishings and with adequate lighting. Sharps, chemicals and medications were located in locked cabinets/closets and cupboards. LPA observed sufficient seating under covered patio areas.

The following deficiencies were observed during todays visit: Water temperature measured at 121.6 degrees in hallway bathroom sink. This poses a potential health safety and personal rights risk to residents in care. Deficiency issued on attached 809D. If not corrected, deficiencies will have a direct impact on residents in care.

LPA requested the following documents to be submitted to CCL by 05/01/26: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-D), Affidavit regarding Resident Cash Resources (LIC 400), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

Exit interview was conducted with Licensee, Floray. A plan of correction was developed by Licensee and reviewed by LPA. A copy of this report, deficiencies and appeal rights provided.