Facility Evaluation Report

At approximately 12:10 p.m. on 05/27/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the licensee and disclosed the reason for the visit.

The facility was last visited on 04/09/2024 for an annual inspection. It is a gated, single story building with seven (07) bedrooms and eight (08) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) bedridden residents. The facility serves residents with dementia. Approved hospice waivers for six (06).

At the main entrance, LPA observed two (02) residents relaxing in the shaded patio area with family. Once inside, postings were observed for confidential complaint contacts, ombudsman contacts, facility license, administrator certificates, facility sketch with evacuation routes clearly labelled, emergency disaster plan, personal rights, rights of resident councils, and neighborhood complaint procedures. A screening station containing a digital thermometer, hand sanitizer, masks, and a visitor log was located at the main entrance.

Walls, floors, windows, screens, and blinds were clean and in good repair. At 12:20 p.m. LPA measured the room temperature to be 74 degrees Fahrenheit. Common areas contained a piano, a karaoke machine, other musical equipment, reading materials, furniture in good repair, and exercise equipment. A fireplace was turned off and grated.

The facility had seven (07) bedrooms in total. One (01) bedroom is designated as a staff room. The staff room was unlocked and free of hazards. All resident bedrooms were private. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. All exit doors were unlocked with auditory alarms on and functioning. All hospital beds had wheels in the locked positions.