Facility Evaluation Report

On 11/18/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required inspection. LPA was greeted and granted entry by Maria Richley Administrator, where LPA explained the purpose of the visit. The facility has an approved hospice waiver for (6), with (3) residents currently receiving hospice services. Currently there are (0) residents receiving home health services, oxygen administration or determined to be bedridden.

The facility was observed to be clean and clutter free. The chemicals, medications and hazardous items were observed to be locked and inaccessible to residents in care. The firs extinguishers were last serviced in November 2025. The emergency disaster drills are being conducted on a quarterly basis with the last drill being conducted on 09/03/25, with the next drill being due in December 2025. The hot water temperature was checked and measured to be 116.5 degrees Fahrenheit. There are no guns or ammunition. The facility is equipped with solar panels, as well as a generator. The facility is utilizing video surveillance in the hallways, and den inside the facility as well as outside. The food supply was sufficient, as well as linens and personal hygiene supplies. The resident bedrooms had the required furniture.

A records review was conducted and the resident files were observed to have the required assessments and completed admissions agreements. The staff present were observed to have criminal record clearance and to be associated to the facility. Staff were observed to have the required training's including Cardio Pulmonary Resuscitation. The administrator was observed to have a valid administrator's certification, which expires on 1/13/26, and had already submitted the necessary paperwork to renew. Based on today's inspection there were no deficiencies issued.

An exit interview was conducted where a copy of this report was reviewed and provided to Maria Richley, administrator.