Facility Evaluation Report

On 03/24/2026, Licensing Program Analyst LPA K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by House Manager / Designee Connie Powell (HM). Administrator was contacted via telephone and was unable to meet.

LPA conducted tour with Staff. The facility was observed to be at a comfortable temperature, in good repair, with no passageway obstructions or fire hazards. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Fire extinguisher in the Kitchen was last serviced on 01/28/2026 and was fully charged. All common areas were properly furnished and well-lit throughout. First Aid is kept in kitchen cabinet. LPA observed sharps kept in locked kitchen cabinets. The tour continued to laundry area adjacent to kitchen which leads into the garage. LPA observed unlocked laundry detergent and chemicals in the laundry area. Additional chemicals are kept in locked cabinets in garage. Smoke Alarm and Carbon Monoxide detector tested and operational. LPA observed medication locked in hallway closet. LPA viewed the staff bedroom downstairs and a common half bath. The exterior tour was conducted. The backyard was observed to have sufficient shaded area for rest and recreation.

LPA toured 3 residents’ bedrooms upstairs. LPA observed stairwell carpet and bedroom carpets to have dirt and debris. All client bedrooms toured and observed to be adequately furnished. Resident bedroom window screen observed torn. Extra linens observed in the hallway cabinets. Staff records were reviewed for good health and training, all clients’ records reviewed to have Admission Agreement, Physician’s Report and emergency contact information. During medication audit LPA observed resident (R1) was being given PRN