Facility Evaluation Report

Licensing Program Analyst (LPA) Abeye Duguma met with Edna Provost for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 2:45p.m. and the following was noted:

The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water.

There is one entrance being utilized at the facility. The facility has a total of five (05) bedrooms and two (02) bathrooms for both residents and staff. The facility is fire cleared for six (06) non-ambulatory of which one (01) may be bedridden, and a hospice waiver for two (02). The facility is currently occupying six (06) residents.

The living and dining room are neat and clean. The facility maintains a comfortable temperature at 74°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located near the kitchen and observed to be fully charged and last inspected 12/11/2025.

Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. (continued on LIC 809-C)