Most inspections were clean, including the initial licensing visits in October and November 2023, which found the facility in good repair and operating safely with no deficiencies. The most recent inspection on November 19, 2024, cited two minor deficiencies related to medication management, specifically incomplete medication administration records and medication not stored in original containers. No serious issues such as fines, enforcement actions, or harm-level findings were noted in any report. The facility was otherwise clean, safe, and well maintained throughout the inspections. These findings suggest some room for improvement in medication handling, but overall compliance appears stable.
The inspection was an unannounced required annual visit to the facility conducted by the Licensing Program Analyst to evaluate compliance with licensing regulations.
Findings
The facility was found to be operating within its approved capacity, clean, in good repair, and safe for residents. However, two deficiencies were cited related to medication management, including incomplete medication administration records and medication not stored in original containers. One technical advisory was also issued.
Severity Breakdown
Type A: 2
Deficiencies (2)
Description
Severity
Medication was removed from its original container, violating storage requirements.
Type A
Medication Administration Records (MARs) were incomplete and not properly signed for 2 residents.
Met during inspection and named in medication deficiency findings
Lavette Farlow
Licensing Program Analyst
Conducted the inspection and authored the report
Nedra Brown
Licensing Program Manager
Supervisor overseeing the inspection
Inspection Report Original LicensingCapacity: 6Deficiencies: 0Nov 6, 2023
Visit Reason
The visit was conducted as a pre-licensing inspection for Cassandra's Care Home to evaluate readiness for licensing as a Residential Care Facility for the Elderly (RCFE).
Findings
The facility was found to be clean, in good repair, and operating in safe conditions with no deficiencies observed. All areas including resident rooms, bathrooms, kitchen, living and dining areas, and outdoor spaces met regulatory requirements.
Report Facts
Fire clearance: 6Fire extinguishers: 2Water temperature: 110
Employees Mentioned
Name
Title
Context
Amber Coleman
Licensing Program Analyst
Conducted the pre-licensing inspection and authored the report.
Cassandra Ellison
Administrator/Licensee
Facility administrator and licensee present during inspection.
Inspection Report Original LicensingCapacity: 6Deficiencies: 0Oct 18, 2023
Visit Reason
Initial licensing evaluation visit to assess the applicant's readiness and understanding of community care facility licensing laws and regulations.
Findings
The applicant/administrator successfully completed the Component II evaluation, demonstrating understanding of facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints reporting, and pre-licensing readiness.
Employees Mentioned
Name
Title
Context
Cassandra Ellison
Administrator
Applicant/licensee and administrator participating in the Component II evaluation.
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