Facility Evaluation Report

On 4/15/25 at 12:35 PM, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPA was greeted and granted entry into the facility by care giving staff after explaining the purpose for the visit. Compliance Manager/Administrator (AD) Michelle Nesbitt and Executive Administrator (EA) Jozef Springer were notified via telephone and later arrived to assist with the inspection. LPA observed that Compliance Manager/Administrator Michelle Nesbitt has a valid Administrator certificate which expires on April 11, 2026.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents and has a hospice waiver for six. The facility is a single story home with five resident bedrooms, one of which is shared, two staff bedrooms, three resident bathrooms, a living room, a dining room, a kitchen, a laundry room, and an attached two car garage. LPA, accompanied by the AD, conducted a tour of the interior portion of the facility. On today's visit, LPA observed five residents in care and three care giving staff present. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPA inspected the five resident bedrooms and they were observed to be free of hazards. LPA observed resident bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA observed additional linens to be stored in a hallway cabinet. LPA inspected the three resident bathrooms and they were observed to be clean. Resident bathrooms are equipped with grab bars and nonskid floor mats. Faucets and toilets were operational. Hot water temperature measured between 107.7 and 118.2 degrees Fahrenheit. LPA observed the two staff bedrooms to be kept locked and inaccessible to residents in care.