Facility Evaluation Report

On 08/04/25, Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived at the facility unannounced to conduct a required 1 year inspection utilizing the care tool. LPAs met with Administrator Sheri Kimbro and explained the purpose of the visit.

LPAs and Administrator conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to residents bedrooms, kitchen, bathrooms, dining room, common areas, storage area, and laundry area. LPAs observed required furniture, and lighting throughout the residents' bedrooms and facility. LPAs observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Hot water temperature was measured at 108 degrees Fahrenheit in a residents bathroom, which is within the required range of 105 to 120 degrees. The temperature in the facility was 73 degrees. First aid kit was completed. LPAs observed fire detectors and carbon monoxide detectors to be operable. LPAs observed the fire extinguisher, located in common areas which were ready for emergency use. LPAs reviewed fire and disaster drill logs, which are conducted quarterly. LPAs observed required Licensing posters posted throughout the facility.

LPAs conducted a file review of five (5) staff and five (5) residents records. Resident records were found to be complete. Staff records were incomplete and citations were issued as indicated on LIC809-D.

Medications are centrally stored, locked, and were inaccessible to residents.

Deficiencies were observed and cited during today's inspection per Title 22 Regulations.

Exit interview conducted ,appeal rights and copy of the report was left at the facility.