Facility Evaluation Report

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Administrator (AD) Christiana Stan at 8am and explained the purpose of the visit. LPA explained to AD that this visit is for the 2026 calendar year and introduced self as their new assigned LPA.

The facility is a two story residential home in which the first floor has five bedrooms and three bathrooms for residents. One of the Adminstrators resides on the second floor in which residents do not have access. The facility has a fire clearance for five non-ambulatory and one ambulatory in which one resident may be bedridden. The facility has an approved hospice waiver for two. Currently the facility has a census of five residents; in which three receive hospice services. A deficiency was given on April 29, 2026 and the facility has submitted a letter to the Department on April 29 2026 for an increase of the hospice waiver. Per Department communications on May 26, 2026, AD will be notified of a decision once it has been made.

During the visit LPA toured the exterior of the property and there were no hazards or obstructions in pathways. There is a covered shaded seating area and there is ample space for outdoor activities. There are two exterior gates for the property and a garden. One exterior gate is locked overnight but is unlocked during the day.

LPA tested the hot water temperature in three of three resident bathrooms. The hot water temperature was between 109.5 to 113.3 degrees Fahrenheit. Bathrooms had non-skid flooring and grab bars. The PUB 475 See Something, Say Something poster was observed in the office and the fire extinguisher was charged and inspected on June 8, 2026. The facility's last fire drill was on June 10, 2026. LPA tested and inspected