Facility Evaluation Report

On 07/17/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA was greeted by staff member, Lydia Wilkie and explained the the purpose of the visit. LPA also called the Facility Designated Administrator (FDA), Sherry Ahuja and informed her that CCL was present at this time. It was stated by FDA Ahuja that she would be at the facility within 30 minutes. There was one other staff member present at the time of LPA Pascua's arrival, Ryan Mapp.

Current census was 5. This facility is licensed to serve 6 residents who are 60 and older. Of the 6 residents, all may be on hospice, 3 may be non-ambulatory and 1 may be bedridden. The bedridden room is cleared by the local fire department for bedroom #5 only. In addition, non-ambulatory residents may reside only in bedrooms #3 and bedroom #4. Ambulatory residents are to reside in bedroom #1 and #2. Bedroom #2 is the only shared bedroom at the time of the fire clearance.

LPA reviewed 5 resident files. Based on the file review conducted, it was learned that 5 out 5 resident files did not have a current needs and services plan. 3 out 5 residents did not have an inventory sheet or a pre placement appraisal. LPA reviewed 3 staff files. Based on filed review conducted, it was learned that 3 out 3 staff members do not have current annual training and staff files appears to have documentation from prior facility. The current FDA has an active administrator certificate #7027497740 and expires on 01/30/2026.

A tour of the kitchen was conducted. LPA observed a sufficient amount of 2-day perishable and 7 day non-perishable food supply. LPA observed knives and toxins locked and made inaccessible to residents in care.