Facility Evaluation Report

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Licensee Josephine Credo. Facility currently has three (3) residents, two (2) of which are on hospice.

At approximately 9:30am LPA toured the building and grounds. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and most were labeled. Cleaning supplies were locked in the laundry room. Kitchen drawer with sharp knives locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 112.3 degrees F which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 2/16/26. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drill was conducted last conducted 3/28/26 . Facility has a backup generator for use during a power outage. Facility has large pile, approximately 4 feet tall, of dried leaves, branches, and elements of tree that was cut down. Per licensee, tree was just cut down this weekend and all brush will be removed by 6/11/26.

At approximately 11:30am LPA initiated file review. LPA conducted a review of three (3) resident records. Resident (R1) in room #2 is bedridden and on hospice. However, licensee could not show documentation of notification to fire department ( deficiency cited, see 809D ). Resident (R2) did not have TB clearance on file.