Facility Evaluation Report

At 8:00am on 01/292026, Licensing Program Analyst (LPA) Mark Jeffries arrived at the facility to conduct an unannounced annual inspection. LPA met with Administrator Ashley Holmes and explained the reason for the visit. This facilities last annual inspection was conducted on 02/04/2025.

LPA toured facility with Administrator and Assistant Administrator. The facility is maintained in conformance with state fire marshal regulations. There are two private bedrooms and one shared bedroom for four residents in care. All bedrooms are sufficiently furnished with lighting, night stands, beds, and bedding. There is one half bathroom and one full bathroom. All clients have access to each bathroom. Smoke detectors and carbon monoxide detectors functioning throughout the facility. Fire extinguisher was fully charged. Inside and outside passageways are free from obstruction. There are no bodies of water on the facility property. The facility temperature was 70 degrees F. Hot water temperature tested and read at 113.6 degrees F at 9:45AM. Residents’ rooms are appropriately furnished with adequate lighting. LPA observed more than two days of perishable and more than seven days of non-perishable food. A written disaster and emergency Disaster Plan is located on the facility kitchen wall. This facility has all 4 residents vended through Tri-Counties Regional Center (TCRC). LPA observed clients being treated with dignity and respect.

LPA reviewed client and staff files. All client files reviewed have current physicians report including TB screening, current needs and services plans and admission agreements. Staff files reviewed had current first aid certificates, health screenings including TB screening and adequate training hours.

LPA reviewed medications. Medications are stored in a locked cabinet in the Laundry room. There is a signed and dated order from a physician for prescription and PRN medication. LPA observed the medication administration record (MAR) and Centrally Stored Medications records and medications are given per physician's orders.

Exit interview, no deficiencies cited, report given.