Facility Evaluation Report

Licensing Program Analyst (LPA) Talwinder Bains arrived on 09/15/25 to conduct the annual inspection. LPA met with staff, Sevrena Miller (S1) and explained the purpose of today's visit.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used.

LPA checked the medications for two (2) residents and no errors were identified. LPA reviewed two (2) residents files and two (2) staff files and found them to be complete.

LPA and S1 toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. LPA checked the kitchen area for the ability to prepare and store food. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire Extinguisher was last serviced on 03/06/25 and was ready for emergency use. Inside temperature was 76 degree F during visit. Facility was conducting fire and disaster drills per requirement.

Several topics were discussed. LPA requested a copy of the LIC308, LIC 500, LIC610E and current liability insurance to be sent to the Department by 09/30/25.

No deficiencies were observed and cited per Title 22 Regulations from this visit.

Exit interview conducted. Copy of this report was provided.