Facility Evaluation Report

On 7/24/2025, Licensing Program Analysts Kimberly Viarella and Arvin Villanueva (LPAs) conducted an unannounced Case Management annual continuation visit at the facility to continue with the Annual visit initiated on 7/16/2025. LPAs met with staff on duty, Etta Mae Shaw and stated the purpose of the visit. The Administrator Beatrice Clark was notified of the visit. During this visit, LPAs conducted facility observations.

In bedroom #3 from the facility sketch, LPAs found medication labeled Albuterol Sulfate inside the closet. LPAs also observed hygiene supplies inside resident drawers.

The fire door leading to resident bedrooms was observed to be propped open with a shoe/sandal. This was also observed during the initial visit on 7/16/25.

In bedroom #1 from the facility sketch, LPAs observed resident bed to be blocking the resident drawer, making it difficult to access resident belonging stored inside the drawer.

In bedroom #2 from the facility sketch, LPAs observed resident do not have a bed but is using a reclining chair. Per discussion with resident from the initial visit on 7/16/25, resident does not use a bed. Per discussion with Beatrice, it is a personal choice of the resident. Also, this room does not have a closet door. Per discussion with Beatrice, resident do not want to have a door for easy access to their belongings. LPA Villanueva confirmed this with the resident.

In bedroom #4 from the facility sketch, LPAs observed the presence of ants on the floor near the resident dresser. The ants were also observed from the initial visit on 7/16/25. LPAs also observed a walker inside the closet. Per interview and record review, the resident residing in this bedroom is considered non-ambulatory as evidence by the presence of walker and resident is using wheelchair during the visit.