Facility Evaluation Report

On 07/23/2025, Licensing Program Analyst (LPA) Daiquiri Boyd arrived at the facility unannounced to conduct a required Annual Inspection visit. LPA introduced herself, stated purpose of visit, and was allowed entrance by staff. Administrator Lita Williams was contacted, and arrived shortly after.

LPA toured the facility inside and out including entry, kitchen, dining, living room, bedrooms, bathrooms, and exterior. LPA observed facility to have a sprinkler system, Administrator stated it has checked by the fire department, but they do not have any documentation. Medications are stored in a locked cabinet in the dining room. Knives and sharp objects are secured in the kitchen. LPA observed chemicals to be locked up in the garage and under the kitchen sink. There is an upstairs to the home, which is only used for the Administrator and her sister, who is also training to be an Administrator for this home.

Facility has 9 bedrooms, 6 of which are for residents. There are 4 bathrooms, 2 which are for residents. Residents do not share bedrooms. Last fire drill was recorded as being held on 05/14/2025.

Fire extinguishers show charged and were last serviced 7/24/24. There are smoke alarms in the facility that were tested and working properly. Administrator was unable to provide proof at this time the sprinkler system is in working condition. Carbon monoxide detector was tested and found to not be in working condition. Water temperature was checked in hall bathroom and the kitchen sink and read at 139.6 degree Fahrenheit, water heater was immediately lowered at tank by Licensee.

LPA did observe some of the following deficiencies: medication not being properly recorded on centrally stored log, audio alarms not on in one bedroom, clients do not have updated medical assessments, CPR certificates are expired.