Facility Evaluation Report

Licensing Program Analyst (LPA) Graham Gunby arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with Administrator, Mary Bot, and explained the purpose of the visit.

LPA and Administrator conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to resident bedrooms, bathrooms, kitchen, common areas and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed residents' bathrooms to be clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Toxins and cleaning supplies are locked and inaccessible to residents in care. The hot water temperature was measured in the kitchen sink at 120.9 degrees Fahrenheit. LPA observed fire detectors and carbon monoxide alarms to be operable. The fire extinguisher is located in the kitchen and was last serviced on 12/12/2025. LPA observed required Licensing posters posted in the entry of the facility. LPA observed medications to be locked and inaccessible to residents in care.

LPA reviewed four (4) resident files. Resident files did not contained all required documentation. LPA reviewed two (2) staff records. Staff did not have all required documentation and first aid training.

Exit interview conducted and a copy of the report will be emailed to Administrator.