Facility Evaluation Report

Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct a required annual inspection utilizing the inspection tool. LPA met with staff and explained the purpose of the visit. Staff then contacted Licensee who arrived to the facility shortly afterwards.

Facility currently has five residents in care with one resident on hospice services. Facility is licensed for six non ambulatory, hospice waiver for two. Facility is compliance to licensure.

Today's inspection, LPA and Licensee conducted a tour of the interior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: five residents bedrooms, bathrooms, office, laundry room, and the common areas. LPA observed fire extinguisher present at the facility with recent service date of October 28, 2025. LPA observed bathroom to be free from malodor with presence of paper towels, nonskid mats and personal hygiene products. LPA observed residents bedrooms to be clean with no presence of cleaning supplies, medications and/or sharps.

File review was conducted for five residents and two personnel records. CARE tool was completed and deficiencies were observed. Please see LIC 809-D.

Exit interview conducted and a copy of the report and appeal rights was provided.