Facility Evaluation Report

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 7/3/25 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator arrived to assist.

Upon arrival a sole staff member was present with residents who did not have a criminal record clearance.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. The home is clean. All residents observed to have their care needs met during this inspection.

LPA reviewed 2 resident files. Files are complete and well organized.

LPA reviewed 2 staff files. Files are complete.

LPA discussed updated dementia regulations with Licensee and link to resources was provided.

As a result of this inspection, a deficiency is noted on LIC 809D

Report reviewed and copy with appeal rights were provided.