Facility Evaluation Report

Licensing Program Analyst (LPA) De Leon arrived at 9:30 am to conduct a 1 year annual visit to the facility above. LPA met with Administrator Nikole Daugherty and explained the purpose of the visit.

A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit:

Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectant spray and cleaners. The facility has a 30-day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE).

Physical Plant & Environment Safety: LPA toured 10 residents room and on suite bathrooms. The fire extinguisher were charged and tagged on 08/06/2025. The facility has 15 resident bedrooms with on suite bathrooms, and 1 common area restroom. LPA was authorized to enter and inspect facility. The facility has dual smoke & carbon monoxide detectors with a sprinkler system. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats or textured bottoms. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care and stored in locked storage rooms. The facility has sufficient space inside and outside for activities and visiting. The facility has a patio with furniture, walkways and shaded areas for resident use. The facility is completely fenced with pull up gate latches that are self closing and self latching. The facility has telephone and internet service for resident use. Water tested at 120.0 F.

Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 06/16/2026. The facility is approved for a capacity of 16. The fire clearance is granted for 16 non-Ambulatory, 16 of which may be bedridden. Hospice is approved for 12. The facility has sent in a new admission agreement with rate changed to 90 days and dementia with behavioral expression. Cont. 809-C