Most inspections found no deficiencies, with the most recent report on March 19, 2025, showing full compliance and no issues. Earlier reports were also mostly clean, except for the initial pre-licensing inspection on February 15, 2022, which identified several technical deficiencies related to required postings, emergency supplies, personal protective equipment, and COVID-19 protocols. These issues were addressed by the time of the next inspection in March 2022, which found the facility ready for licensure with no deficiencies. The April 4, 2024 inspection noted two minor technical violations concerning a locked refrigerator and medication audit procedures, but no serious concerns or enforcement actions were reported. Several complaint investigations were unsubstantiated or not applicable, indicating no ongoing problems.
Licensing Program Analysts conducted an unannounced required comprehensive annual inspection of the Residential Care Facility for Elderly to assess compliance with licensing regulations.
Findings
The facility was found to be operating within its licensed capacity with no deficiencies cited. The physical plant, food service, health-related services, and record reviews were all satisfactory and compliant with regulations.
Report Facts
Facility capacity: 6Census: 6Hot water temperature: 116.2Inspection start time: 12.55Inspection end time: 14.4
Employees Mentioned
Name
Title
Context
Brittany Martin
Administrator
Facility Administrator present during inspection and named in report
The visit was an unannounced required annual inspection conducted by the Licensing Program Analyst to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be clean, in good repair, and operating safely with no deficiencies cited. Two technical violations were issued related to a locked refrigerator and medication audit procedures.
Report Facts
Technical violations: 2Residents in care: 5Facility capacity: 6Water temperature: 105.2Fire drill date: Feb 20, 2024
Employees Mentioned
Name
Title
Context
Brittany Martin
Administrator
Facility administrator met during inspection and received report
Michelle Echeverria
Licensing Program Analyst
Conducted the inspection and authored the report
Nedra Brown
Licensing Program Manager
Named as Licensing Program Manager on the report
Casey Kaler
Staff member met by Licensing Program Analyst during inspection
The visit was a case management visit to approve the facility's request for a change from ambulatory to non-ambulatory status for six residents.
Findings
The Licensing Program Analyst toured the facility and inspected bedrooms, finding them in good repair with required furniture and approved the status change. No deficiencies were cited during the visit.
Report Facts
Non-ambulatory status request: 6
Employees Mentioned
Name
Title
Context
Brittany Martin
Licensee
Met with Licensing Program Analyst during the visit and assisted with the facility tour
Rayshaun Nickolas
Licensing Program Analyst
Conducted the case management visit and facility inspection
Karen Clemons
Licensing Program Manager
Named in the report header
Inspection Report Original LicensingCapacity: 6Deficiencies: 0Mar 15, 2022
Visit Reason
This was an announced pre-licensing visit conducted to evaluate the facility's readiness for licensure and to confirm that all required corrections had been made.
Findings
The facility was found to be in compliance with all required regulations, with all previously noted corrections verified as completed. The facility was deemed ready for licensure.
Employees Mentioned
Name
Title
Context
Brittany Martin
Administrator
Applicant/Administrator who assisted in the tour and was involved in the pre-licensing visit.
Melody Brown
Licensing Program Analyst
Conducted the announced pre-licensing visit and evaluation.
Efren Malagon
Licensing Program Manager
Named as Licensing Program Manager on the report.
Inspection Report Original LicensingCapacity: 6Deficiencies: 12Feb 15, 2022
Visit Reason
The visit was a prelicensing inspection conducted to evaluate the facility for initial licensing as a Residential Care Facility for the Elderly.
Findings
The facility was a one-story house with adequate structure and safety features, but the pre-licensing inspection was incomplete due to several deficiencies that must be resolved by 03/10/2022, including posting required notices, providing emergency supply bags, personal hygiene supplies, PPE, and COVID-19 signage and logs.
Deficiencies (12)
Description
Missing Let-Us-No poster
Missing Ombudsman poster
No space for Family Councils on a prominent bulletin board
No emergency supply bag(s) for each resident
No personal hygiene supplies in a caddy for each resident
Missing personal protective equipment supplies (gown, face shield, N95 masks, surgical masks, gloves)