Facility Evaluation Report

On August 22, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to conduct a Case Management Health and Safety visit and met with Licensee, Yvonne Holcombe. LPA explained to Licensee the visit was to confirm the clearance of the Plan of Correction (POC) for a previous matter.

During the visit LPA toured the facility along with the Licensee, Yvonne Holcombe. LPA conducted interviews, record reviews, and made observations pertaining to the previous incident requiring a plan of correction. LPA reviewed the requested documentation, which was faxed previously, to verify clearance of POC. There were no Health and/or Safety issues observed at this time.

LPA conducted a review of the records to include the residents Admissions Agreements, and other required documents at the time of placement. The Licensee informed LPA all residents have scheduled annual visits and current updated TB test.

LPA observed facility utilities to be operating currently. LPA assessed the available food supply and observed there was a variety of food types. Additionally, the supply exceeds the required two-day supply of perishable food items, and a seven-day supply of non-perishable foods.

The medications were found to be locked, and inaccessible to the residents in care, with an automated delivery rotation by Kaiser.

Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were observed or cited during today's visit. The plan of correction for the previous matter was confirmed and verified.

An exit interview was conducted. A copy of this report was reviewed and given to the Licensee, Yvonne Holcombe.