Facility Evaluation Report

On September 17, 2025, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced required 1-Year annual visit. Upon arrival at the facility, LPA Bentley was greeted and granted entry into the facility by staff after stating the purpose for the visit. The Administrator (AD), Shirley Lomeda was contacted and arrived shortly after to assist during the visit. Administrator Shirley Lomeda has an administrator certificate pending renewal received on August 29, 2025.

The facility is licensed for six (6) non-ambulatory residents and has a hospice waiver for six (6). Currently there are six (6) residents on census and all were present during today's visit. Around 9:00am, LPA Bentley toured the physical plant, checked food service, and the first aid kit. The facility consists of four (4) resident bedrooms, one (1) resident bathroom, one (1) staff bathroom, a living room, dining room area, kitchen, an attached two-car garage, and a backyard with covered seating.

Based on observations, interviews, and record review, deficiencies will be cited during next visit due to technical difficulties.

· Facility not in good repair (Pipe leak, non-operational burner, urine smell)

· Curtain on bedroom entrance in place of door, staff sleeping in common areas

· Resident files with outdated Physician’s Report and Appraisals

· Outdated emergency preparedness training

· Emergency supply (low water, expired cans)

An exit interview was conducted, and a copy of this report was provided to Administrator Shirley Lomeda.