Facility Evaluation Report

On 09/04/25, at 12:40 pm, Licensing Program Analyst, (LPA) Ray Comer, arrived for an unannounced case management visit to conduct a facility health and safety observation. LPA met with the Administrator, and reason for the visit was discussed. During the visit, LPA received the following documentation:

3. Resident POA /Conservator contact Information

4. Resident Admission Agreements (which include rent payment source information)

Physical plant inspection : Facility is licensed as a single-story residence, fire clearance for ten (10) non-ambulatory, and one (1) bedridden. Hospice waiver for eleven (11). Facility has eight (8) total bedrooms. Facility has two (2) bathrooms.

All rooms were observed as appropriately furnished, clean, and clear of obstruction. Common areas were observed as clean with shaded patio and seating sufficient for residents. All entrances\exits are equipped with a functioning delayed signaling system. Kitchen area observed with sufficient perishable and non-perishable food. Two (2) residents are receiving hospice services at this time.