Facility Evaluation Report

Licensing Program Analyst (LPA) De Leon conducted a 1 year Annual visit to the facility above. LPA met with Nikole Daugherty, Back up Administrator 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, and hand soap. 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) upon hire and annually thereafter.

Physical Plant & Environmental Safety: LPA toured 10 resident room and 2 have 1/2 baths on suite, 3 common area restrooms and 2 outside cottages with shared a bathroom. The fire extinguisher were charged and tagged on 11/10/2025. LPA was authorized to enter and inspect facility. The facility has dual smoke and carbon monoxide detectors hard wired with 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. 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 room. 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 around the back and side yards with pull up gate latches that are self closing and self latching. The facility has telephone and internet service for resident use.