Facility Evaluation Report

On 3/27/2025, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Caregiver, Tyraj Lanier who was informed of the purpose of the visit. Administrator, James Reed was contacted over the phone and also informed of LPA's visit. The facility has a fire clearance to serve six (6) non-ambulatory elderly residents of which one (1) may be bedridden. The facility also has an approved hospice waiver for six (6) and LPA was informed three (3) residents are currently receiving hospice services at the facility. During the visit, there was two (2) facility staff and four (4) residents present.

LPA toured the facility with Lanier and observed the facility is made up of a one-story home with three (3) resident bedrooms, two (2) bathrooms, a kitchen, dining room, living room, and attached garage. Resident bedrooms had the required bedding, furniture, and lighting. Bathrooms had grab bars, shower chairs, and non-skid mats in the showers. No bodies of water were observed on the premises. Indoor and outdoor pathways were free of obstruction. The facility met Departmental requirements for a two-day supply of perishable foods and seven-day supply of non-perishable foods. Medications are secured in a locked kitchen cabinet. Lanier tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed a charged fire extinguisher mounted near the kitchen that was last serviced on 1/28/2025. The facility's certificate of liability insurance expires on 2/20/2026. Staff present have a criminal record clearance and are associated with the facility. Resident files reviewed had physician's reports and signed admission agreements. Long Term Care Ombudsman's contact information, complaint procedures, facility sketch, and emergency phone numbers are visibly posted near the front entrance and in the living room. During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Lanier.