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25 | At approximately 9:30 a.m. on 10/22/26, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the licensee and disclosed the reason for the visit.
The facility was last visited on 07/10/25 for a complaint visit. It is a single story building with four (04) bedrooms, three (03) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) non-ambulatory residents, of which one (01) may be bedridden in Bedroom #4. The facility serves residents with dementia. Approved hospice waivers for six (06).
At the main entrance, LPA observed postings for COVID precautions, personal rights, rights of resident councils, family councils, neighborhood complaint procedures, theft and loss policy, visitation policy, non-discrimination notice, facility sketch and license, confidential complaint contacts, ombudsman contacts, and administrator certificate. LPA observed the posted administrator certificate was expired. A record review conducted at 11:30 a.m. revealed the last valid administrator certificate expired on 08/08/26. Interview with the administrator at 11:30 a.m. revealed they were nearly finished with the renewal process. A deficiency is cited for an expired administrator certificate on the corresponding LIC 809-D page.
Walls, floors, windows, screens, and blinds were clean and in good repair. At 9:45 a.m. LPA measured the room temperature to be 72 degrees Fahrenheit. Puzzles, board games, and art supplies were provided in the living room. At 9:50 a.m., LPA observed one (01) resident coloring in the living room. At approximately 10:00 a.m., LPA observed a fully charged fire extinguisher near the stove. A receipt was attached from 03/06/26. At 10:10 a.m. LPA and S1 tested all auditory alarms. Three (03) out of three (03) auditory alarms were operational.
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