Facility Evaluation Report

On 9/16/2025 at approximately 09:45 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. LPA was greeted by the caregiver and stated the reason for their visit. The Administrator, Monina Miller arrived shortly after to assist with today’s visit.

LPA asked for the census, Staff/Resident Roster, and Liability Insurance. LPA conducted a physical plant tour at approximately 12:00 PM and the following was noted:

The facility is a single-story building with five (5) bedrooms and three (3) bathrooms. The facility is located a part of a two (2) acre lot with a total of three (3) buildings. The main house for residential use was observed to be within the west wing which was observed to be located behind the main building.

The facility is currently occupying five (5) residents. There is no designated staff room. The facility has an approved fire clearance for six (6) non-ambulatory residents. Hospice waiver approved for four (4).

Common areas: The living room and dining room were observed to be neat, clean, and organized. The rooms were observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 77°F. LPA observed a fire extinguisher to be located alongside the hallway’s passageway and dated 04/16/2025. LPA observed required postings such as Long-Term Care Ombudsman, See/Say Something, and Personal Rights to be located throughout the common areas. A working telephone was observed.

Bedrooms: The residents’ rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. (continued on LIC 809-C)