Facility Evaluation Report

Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a Plan of correction (POC) visit regarding visit on 8/13/2025. LPA met with the caregiver and explained the purpose of the visit. Arvin davis joined about 45 minutes later.

Leah Davis emailed LPA Lewis on 8/15/2025 stating Plans of correction would be completed and the record sent to LPA Lewis by 8/19/2025. This did not occur therefore during todays visit some of the the citations from the visit on 8/13/2025 will be recited. LPA Lewis was able to clear the buildings and grounds POC'S of the grass and bushes overgrown on the exterior of the building blocking walk ways and emergency exits along the exterior. Additionally the two gates latches along the side of the house have been fixed. An exterior exit door from a residents room to the backyard was propped closed and locked with a 2x4 j ammed underneath the door handle this has been removed. A separate e xit from the interior to the exterior was blocked with hoyer lifts and furniture this has been removed. LPA spoke with R1 and asked if they could turn independently in bed and they could not. Medication training has been completed.

Exit interview and copy of report and appeal rights provided.