Facility Evaluation Report

Licensing Program Analyst (LPA) Melisa Rankin arrived at 8:30 a.m. to conduct a 1-year required annual visit. LPA met with Jennifer Villaros, Administrator.

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

Physical Plant & Environment Safety: LPA toured resident rooms and observed that rooms were tidy and free of odor. The lighting and lamps are sufficient for the use of the facility and for resident comfort and safety. Toilet, hand washing and bathing facilities are operational and secure grab bars are present. The showers have slip resistant mats. The pathways are clear of any obstructions. Disinfectants and cleaning solutions are inaccessible to residents in care and locked in closet. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use with plenty of shade. The facility has telephone and internet service for residents’ use. The fire extinguisher was last charged and inspected on 12/8/25. The facility has smoke and carbon monoxide detectors that were tested and working properly.

Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with resident rooms in regard to the granted fire clearance. The facility is approved for a capacity of 6. The fire clearance is granted for 5 non-ambulatory residents and 1 bedridden resident. The facility currently has 5 non-ambulatory resident and 1 ambulatory.

Staffing, Personnel Records & Training: The facility currently employs 4 staff, on-call staff and has 2 administrators who also provide care giving coverage. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. Continued on 809-C