Facility Evaluation Report

Licensing Program Analyst (LPA) Graham Gunby arrived at the facility unannounced on 05/11/2026 to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with Administrator, Michael Ligbit, and explained the purpose of the visit.

LPA reviewed a total of five (5) resident files. Resident files contain signed admission agreements, physician's reports, identification sheets, releases, individual program plan (IPP), and resident rights. Medications are centrally stored, locked, and appear to be given per doctor order. Facility is correctly using the Medication Administration Records (MAR). LPA reviewed a total of three (3) staff records. Staff has training in medications, first aid and CPR, and other various areas of care provision.

LPA and administrator toured the interior and exterior of the facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathrooms, kitchen, and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed food supplies of non-perishables for a minimum of one week and perishable foods for a minimum of two days. Toxic and cleaning supplies locked and is inaccessible to residents in care. The hot water temperature was measured in the kitchen sink at 107.2 degrees Fahrenheit. First aid kit is complete. LPA observed fire extinguisher/carbon monoxide alarms to be in working order and the fire extinguisher to be last service 01/07/2026.

Exit interview conducted and copy of report was emailed to Administrator.