Facility Evaluation Report

On 08/14/2025 at 2:20 PM Licensing Program Analyst Jill Nakagawa arrived unannounced to conduct an Annual Inspection. LPA was welcomed by BHT Travis Jones who contacted the Administrator, who was off-site at a meeting. Administrator Romario Luckhoo arrived shortly.

Facility was found to be clean, orderly, and at a comfortable temperature of 72 degrees F with all exits free from obstruction. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored and locked in a small med. room making them inaccessible to residents. All bathrooms were clean and in good working order, one was just recently renovated, with soap and paper towels. There were 3 carbon monoxide detectors and 7 smoke detectors that were tested and operational at the time of inspection. There were 6 fire extinguishers last serviced on 10/24/2024. There was an adequate supply of perishable and nonperishable food. Water temperature was within regulation. One faucet was above 120 degrees F but labeled with cautionary note.

The facility's grounds were found to be well cared for, with lots of containers of flowers and vegetables. Residents help with the care of the facility and the animals on site, including sheep, goats, a pig, chickens and farm cats.

LPA conducted a review of 4 resident and 4 staff files and found them to be complete. Staff trainings are conducted monthly and ongoing. LPA also went over last DHCS report and found plans of correction had been enacted and completed.

No deficiencies found at the time of inspection. No citations issued.