Facility Evaluation Report

At approximately 2:15 p.m. on 06/03/26, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the licensee and disclosed the reason for the visit.

A file review was conducted prior to this visit. The facility was last visited on 03/12/25 for an annual inspection. It is a single story building with eight (08) bedrooms, two (02) bathrooms, kitchen, office, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which one (01) may be bedridden. The facility serves residents with dementia. Approved hospice waivers for four (04).

At 2:25 p.m. LPA reviewed resident and personnel files. All files were complete, updated, and available for audit. The front entrance was gated and unlocked. The front yard was maintained. Once inside, LPA observed postings near the main entrance and the office area for Ombudsman contacts, confidential complaint contacts, facility license, COVID precautions, emergency disaster plan, facility sketch, personal rights, rights of resident councils, liability insurance, and emergency contacts. A screening station at the front contained a visitor log, gloves, masks, and sanitizer.

Walls, floors, windows, screens, and blinds were clean and in good repair. At 3:20 p.m. LPA measured the room temperature to be 74 degrees Fahrenheit. The living room contained televisions, reading materials, board games, and exercise equipment. A fireplace was appropriately grated with the gas line turned off. Medications, first aid kit, and confidential files were locked near the dining room.