Facility Evaluation Report

Licensing Program Analyst (LPA) Vaid conducted an unannounced annual inspection visit. LPA met with Licensee /administrator Tracy Martin, who assisted with the visit. The facility is licensed to serve elderly, ages 60 years old and older and has two (2) approved hospice waivers. The facility capacity is five (5) including three (3) ambulatory, two (2) non- ambulatory and zero (0) bedridden. The facility has dementia program in place. Annual fees are current. Administrator certificate is current with expiration date on 6/26/2026. No residents were interviewed as resident census is zero (0).

During the visit, LPA conducted staff interviews, used CARE inspection tools, toured the facility, reviewed food supply, and reviewed staff records. Since the facility has not admitted resident, thus, resident interview, resident record review and medication were not conducted.

The facility is a two-story house with four (4) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, living room, kitchen, dining room, family room, backyard with patio, activity area in the garage, and laundry room. The residents’ bedrooms are spacious and will easily accommodate with the residents’ furnishings. Exits are installed with alarm auditory devices.

Medication will be centrally stored in a locked medication cabinet and inaccessible to residents in care. All rooms are furnished with appropriate furniture for residents’ comfort. Bathrooms are furnished with grab bars and nonskid surfaces. Common areas and outdoor areas are observed for the ability to safely serve the needs of the residents. Hot water temperature is measured between 105-120 degrees Fahrenheit.

Sufficient of linen supplies and personal hygiene supplies were observed. Sufficient supply of perishable and non-perishable foods was observed. Refrigerators, freezers, microwaves, ovens and counter tops observed to be clean. Plates, cups, glasses and utensils are sufficient for the current census.

Smoke detectors and carbon monoxide detectors were tested and operable. Fire extinguishers were fully charged. All mandated documents and signages are posted in common areas.

No deficiency was observed, an exit interview was conducted and provided to Licensee Tacy Martin.