Facility Evaluation Report

On 06/16/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA met with Staff member (SM), Lillie King and explained the purpose of the visit. LPA Pascua asked SM King to call the Facility Designated Administrator (FDA), Saudia King to inform her that CCL was present at this time. Shortly after, LPA met with Facility Designated Representative, (FDR) Sheila McGinty

This facility is licensed to served and accept up to 6 residents who are deemed to be ambulatory only. This facility is also vendorized to accept and retain Level 3 residents at this time.

Current census was 5. 5 out 5 residents were out at their respective day program at this time.

A brief interview with the FDR McGinty was conducted.

LPA reviewed 5 resident files. 5 out of 5 resident files have been current and up to date. LPA reviewed 3 staff files. 3 out of 3 staff files are current and up to date. The FDA has an active and current administrator's certificate #7034047635 and expires on 08/30/2026. The FDR also has an active and current administrator's certificate #6076209735 and expires on 03/16/2027. It was stated that FDR McGinty will be the administrator moving forward.

Carbon monoxide and smoke alarms were tested and were in working condition.

The kitchen area was toured. LPA observed a sufficient amount of 2-day perishable and 7 day non-perishable food supplies in the refrigerator and cabinets. Fire extinguisher was present and was serviced on 02/21/2025. Knives were observed to be locked in a kitchen cabinet and made inaccessible to the residents at this time.

LPA observed a locked centralized stored medication located in the kitchen cabinet. Along with the administrator, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.