Facility Evaluation Report

On 07/02/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a case management other visit. LPA met with Lead Caregiver Tyla Kincherlow and explained the purpose of the visit. At the time of the visit there was (1) staff and (1) resident present.

Upon arrival LPA observed for there to be a Volunteer #1 (V1) whom has fingerprint clearance but, is not associated to the facility and was left alone with the resident in care, a deficiency is being cited , and $300 civil penalties are being assessed, as V1 has been a volunteer since 06/30/25. Lead Caregiver Tyla Kincherlow arrived 5 minutes after LPA. LPA conducted a review of the following outstanding items:

-Status of administrator certification for Caregiver Tyla Kincherlow, proof of completion of CEUs as well as a money order for the fees was observed and obtained. The deficiency was cleared.

-On 04/14/25, there was no proof of an emergency disaster drills that were conducted and a citation was issued during the annual inspection conducted. During today's visit there was no proof of an emergency disaster drill being completed therefore the citation is being reissued.

-On 04/14/25 a citation was issued for the facility not having valid liability insurance and a citation was issued. During today's visit the status is the same, as the facility does not possess a valid liability insurance policy, therefore the citation is being reissued.

-On 04/14/25 a citation was issued due to there not being a staff that possessed valid CPR certification. During today's visit proof was provided and the deficiency was cleared.