Facility Evaluation Report

At approximately 12:55 p.m. on 02/24/26, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the administrator and disclosed the reason for the visit.

A file review was conducted prior to the visit.

The facility was last visited on 02/05/25 for an annual inspection. It is a single story building with six (06) bedrooms, four (04) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents. Approved hospice waivers for six (06).

At the main entrance, LPA observed a maintained front yard with stairs leading to the unlocked main entrance. The driveway was free of debris. Postings were observed for confidential complaint contacts, ombudsman contacts, personal rights, rights of resident councils, nondiscrimination notice, neighborhood grievance procedure, emergency disaster plan, facility license, facility sketch, administrator certificate, and a blank copy of an admission agreement. A sign showing “No smoking – Oxygen in use” was posted at the main entrance.

Walls, floors, windows, screens, and blinds were clean and in good repair. The living room contained furniture in good repair, reading material, puzzles, art supplies, and exercise equipment. An office was locked and contained confidential files and medications. A linen closet near Bedroom #4 contained an adequate supply of fresh linens, PPE, and hygiene supplies. A locked closet near the office contained medications and a fully stoked first aid kit. Four (04) out of four (04) auditory alarms were tested and functional. LPA observed a covered patio area in the rear of the facility. At approximately 1:15 p.m. the room temperature to be 76 degrees Fahrenheit.