Facility Evaluation Report

Licensing Program Analyst (LPA) Daniel Konishi conducted the Unannounced required annual inspection. LPA arrived unannounced and met with the Executive Director, Mary Mims-Burris and assisted with the visit. The purpose for the visit was explained. The facility is licensed for residents ages 60 and over. The fire clearance is approved for 49 ambulatory and 111 non-ambulatory. Currently, the facility has 11 hospice waiver residents and 6 home health residents.

The initial annual visit was conducted on 04/24/2025. During the initial visit the following eight (8) Compliance and Regulatory Enforcement (CARE) tool domains were observed and reviewed: Infection Control, Operational Requirement, Physical Plant Environmental Safety, Resident Right-Information, Planned Activities, Food Services, Incidental Medical and Dental, Disaster Preparedness.

During today’s annual visit, the following four (4) Compliance and Regulatory Enforcement (CARE) tool domains were observed and reviewed: Staffing, Personnel Records-Training, Resident Records-Personnel Reports, Resident with Special Health Needs.

Staffing: Facility has sufficient staffing for care and supervision to the residents.

Personnel Records-Training: All the staff in the facility are over 18 years old and fingerprint cleared with the facility. The administrator is Mary Mims-Burris and her administrator certificate expires on 10/02/2025. LPA reviewed all nine (9) staff files and they all have the required documents in file which included: health screening, TB test result, employee rights, required training hours and updated first aid certificate.