Facility Evaluation Report

On 1/31/26, 8:00 am, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced annual visit to this facility. LPA met with Facility Administrator, and reason for the visit was discussed.

Facility is licensed as a single-story residence. Fire clearance approved for six (6) Non-ambulatory residents, and one (1) bedridden. Hospice waiver for six (6). Facility has six (6) total bedrooms, (four private bedrooms, one shared bedroom, and one staff bedroom) with four (4) total bathrooms.

At 8:20 am, LPA conducted a tour of physical plant with the Administrator and observed the following:

Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Screening area is located immediately upon entrance. Visitor sign-in sheet, hand sanitizer, gloves and masks are available. Room temperature is comfortable; wall thermostat displays a setting of 72.0°F., within the required range. An approved Mitigation and Infection Control plan is on file. Hand washing, coughing etiquette, and other necessary signage are prominently displayed throughout the facility. Required postings observed to be current. Disaster drills were last conducted on 1/02/26.

Fire Detection/Protection system is present in the facility. Dual Smoke and Carbon Monoxide detectors were tested and function properly. LPA observed two (2) fire extinguishers located in the dining room, and in the hallway. Extinguishers display service date: 12/25/25.