Facility Evaluation Report

On this day, Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents, of which three may be bedridden. Facility has an approved hospice waiver for 3 residents and the home currently has 5 residents. There are no residents on hospice during today's visit. Administrator Jaya Pichika has an administrator certificate that has expired on 09/13/2025. Administrator indicates applying for re-certification in March 2026.

LPA Lyman along with Administrator Pichika toured the facility at 7:56 AM. LPA toured the physical plant, checked food service, facility documentation and the first aid kit. The two story home consists of 6 resident bedrooms, tenant room, owner occupied room, living room, dining room, and kitchen as well as 4 restrooms. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. At 8:00 AM, LPA observed Resident 5's (R5) smoke detector has been removed from the resident's room. LPA observed unsecured Tylenol in R2's room. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 114.4 degrees F and 118.2 degrees F in tested restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. LPA observed exit doors in R1 and R2's rooms are difficult to open and require full body strength to open. The two rooms are designated as bedridden. LPA toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. LPA observed a broken cabinet in kitchen. Smoke detectors tested operational during today's visit. Fire extinguisher is fully charged.