Facility Evaluation Report

Licensing Program Analyst(s) Sommer Hayes and Kimberly Viarella arrived unannounced to conduct the 1-year Annual Inspection visit on 04/21/25. LPAs introduced themselves, stated the purpose of their visit and met with the Designated Facility Administrator, Victoria Kachan.

LPAs compared the LIC 500 (the staff roster) with the Guardian roster to ensure that all employees had their required clearances to care for the residents. All were in compliance at the time of this inspection.

The inspection began with a review of the medications which were located in locked cabinets and inaccessible to residents in care. LPA reviewed storage, administration and destruction procedures with Kachan. The first aid was also inspected and contained all the required elements to be in compliance.

LPA Hayes inspected the food supply and found there to be a 7 day supply of non-perishable and a 2 day supply of perishable food items. All knives and sharps were locked and inaccessible to residents in care.

LPA observed that the fire extinguisher was last inspected on 02/11/25 by River City Fire Co. and was in compliance at the time of this inspection.

LPA Hayes then inspected all of the resident rooms to ensure that they contained the required furniture, furnishings, and lighting . All rooms were in compliance at the time of this inspection.

LPA inspected 3 bathrooms and observed that they all contained the required soap, paper towels, grab bars and trash cans as required at the time of this inspection. Hot water was measured and found to be 107 degrees Fahrenheit and in compliance.

The exterior of the building was also inspected by LPA Hayes. All windows, window screens, and gutters were in good repair and there was a shaded area with seating for residents to enjoy.