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 Lorna Smith, Administrator (AD) and explained the purpose of the visit.

The facility is a four bedroom, two bathroom residential home with an approved fire clearance for six non-ambulatory residents and a hospice waiver for six. The facility has been undergoing construction for a permitted extended patio and bedroom so the entrance through the patio is not accessible at this time. There are currently two residents in care and neither resident receives hospice services. AD recently completed the Department's Technical Support Program (TSP) on May 18, 2026.

The facility was 72 degrees Fahrenheit, was clean and no odors were detected. The smoke and carbon monoxide detectors were inspected and were operational. The fire extinguisher was charged and inspected on May 26, 2026. The hot water temperatures were measured in two of two resident bathrooms. The temperatures ranged from 105.9 to 107.6 degrees Fahrenheit. Bathrooms had non skid mats and covered trash cans. Four of four bedrooms had the required furnishings and linens.

LPA toured the kitchen and appliances were in working order. Fresh fruits were observed on the countertop. Sharps and knives were secured in a locked drawer and cleaning supplies and chemicals were locked beneath the kitchen sink. The refrigerator had two days of perishable food supplies and the pantry and freezer had seven days of non-perishable items on hand. Additional food items were in the garage with a washer and dryer and staff refrigerator.