Facility Evaluation Report

At 9:35am on 09/18/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the facility annual inspection. LPA met with Administrator, Nemia Defiesta, announced who he is and the reason for the visit.

This facility is a six single resident occupancy bedrooms, three bathroom, two of bathrooms are shared by all residents and staff, and room #1 has an on suite bathroom that is for use only of resident residing in room #1. The facility has a large living room, dining room, and kitchen. There is a fenced yard in the back and side with chairs, and table under a pergola for shad. There is sufficient room for activities and visiting, both inside and outside the facility. LPA observed duel smoke detectors and carbon monoxide detectors located throughout the facility that are hard wired and working properly. There is a fire extinguisher located in the kitchen that is primed and in the green. LPA noted the facility water temperature is within regulation perimeters of 105*-120*(f). LPA noted that there is a more than 72 hours of emergency water located in the garage. LPA note in the locked medication cabinet is located in the living room and a complete first aide kit is also located in the medication cabinet. LPA noted that all bedrooms have regulation required furnishings and linins. LPA noted that all bathrooms have liquid soap and paper towels. LPA noted that the facility was clean and in good repair and all exits, door ways, and passage ways were free and clear of obstacles. LPA conducted a cursory review of facility emergency disaster plan, infection control plan, staff files and training records, client files and Centrally Stored Medication Records (CSMR). LPA noted that there were no violations or citation issued as a result of the annual facility physical inspection.

LPA conducted a full review of annual care tools and noted no violations or citations. No violations or citations issued as a result of this full facility annual inspection, Exit interview, report read, and report provide.