Facility Evaluation Report

At approximately 12:45 PM Licensing Program Analyst (LPA) Stevenson arrived to conducted a Annual Required inspection. There are currently no residents in care. Facility is approved/cleared for 6 non-ambulatory residents, one of whom could be bedridden. Facility has a hospice waiver for 6. Facility hasn't had any residents in care since February 2025. LPA met with Licensee Denise O'Reilly who is in the process of becoming the Administrator of Record.

Facility is a two-story building with a large bonus room upstairs that will not be used by residents.

LPA and licensee toured the building and grounds. All rooms were furnished per regulation. All rooms were in good repair. Extra linens were available. Water temperature in sinks were measured within the range of 105 to 120 degrees F. Fire extinguishers were charged and last tested May 2025. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins, sharps and other items that could pose a risk if available to residents were located in the laundry room and under the kitchen sink and found to be secured.

Facility has well constructed ramps in the front and back, as well as, shade and sun areas for residents to use. Facility is noted to have several televisions, and access to games, and a sunny exercises room.

A staff bathroom off the kitchen is noted to enter into a Resident's private room and licensee is advised to keep the door locked between this bathroom and private Resident room. Licensee is asked to place signs on the door banning staff from entering that staff bathroom from the private resident bedroom, as well as, using that staff bathroom door to enter the private bedroom to ensure privacy for residents in care at all times.