Inspection Report
Deficiencies: 0
Aug 26, 2025
Visit Reason
The visit was a Construction Section Biennial Survey conducted to assess compliance with construction-related regulations.
Findings
No deficiencies were cited during the survey. No further action is necessary.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tod Hancock | Conducted the Construction Section Biennial Survey |
Inspection Report
Annual Inspection
Census: 26
Capacity: 49
Deficiencies: 1
Oct 20, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual survey of The Little Flower Assisted Living facility on October 20, 2022.
Findings
The facility failed to ensure that 7 of 8 exit doors accessible to residents had audible alarms activated when opened, despite 12 of 26 residents being intermittently or constantly disoriented and ambulatory or semi-ambulatory, including at least one resident with wandering behaviors. This posed a safety risk due to the facility's proximity to a busy road and unsecured outdoor areas.
Severity Breakdown
Type B Violation: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure 7 of 8 exit doors accessible to residents had audible alarms activated when opened for the safety of residents who were disoriented or wanderers. | Type B Violation |
Report Facts
Licensed beds: 49
Residents present: 26
Exit doors without audible alarm: 7
Residents disoriented and ambulatory: 12
Speed limit: 45
Inspection Report
Follow-Up
Deficiencies: 1
Jul 3, 2019
Visit Reason
Biennial Follow Up Construction Survey conducted to verify correction of previously identified deficiencies.
Findings
A deficiency related to building equipment maintenance was not properly corrected; specifically, the outside porch floor in the exit path had a 1.25 inch drop-off creating a trip and fall hazard.
Deficiencies (1)
| Description |
|---|
| Outside porch floor in the path of exiting was not maintained in a safe and operating condition due to a 1.25 inch drop-off between the porch floor and the top of the ramp. |
Report Facts
Drop-off height: 1.25
Inspection Report
Capacity: 49
Deficiencies: 5
May 20, 2019
Visit Reason
The inspection was a Construction Section Biennial Survey to ensure compliance with applicable regulations and building codes for the licensed assisted living facility.
Findings
The facility was found deficient in fire safety rehearsals documentation, building equipment maintenance including fire door latching and fire-rated ceiling penetrations, porch floor safety, and exhaust ventilation in certain closets.
Deficiencies (5)
| Description |
|---|
| Records of fire safety rehearsals lacked sufficient description of what the rehearsals involved. |
| Corridor doors prevented from closing quickly and latching properly, including a chapel door and a door to room 9 not fitting properly to resist smoke passage. |
| Unsealed pipe penetration in the ceiling of the upstairs equipment room compromising the one-hour fire rated ceiling. |
| Considerable rot and buckling of the outside porch floor on the West side, not maintained in a safe and operating condition. |
| Exhaust ventilation was not working in the mop closet and the priest closet. |
Report Facts
Total licensed beds: 49
Inspection Report
Capacity: 49
Deficiencies: 1
May 25, 2017
Visit Reason
This is a Construction Section Biennial Survey to ensure the facility meets applicable building and safety regulations.
Findings
The facility was found to have deficiencies related to building and fire safety equipment maintenance, specifically the Med Room entry door being out of adjustment with air gaps greater than 1/8 of an inch, which could allow the spread of fire and/or smoke beyond the room of origin.
Deficiencies (1)
| Description |
|---|
| The Med Room entry door is out of adjustment and has air gaps around the door stops greater than 1/8 of an inch, compromising fire safety. |
Report Facts
Licensed capacity: 49
Inspection Report
Capacity: 49
Deficiencies: 21
May 6, 2015
Visit Reason
Biennial Construction Survey conducted to assess compliance with physical plant, fire safety, and other regulatory requirements for an adult care home licensed for 49 beds.
Findings
The survey identified multiple deficiencies including fire safety issues such as compromised fire rated walls and ceilings, non-latching corridor and fire doors, clogged dryer vents, improperly stored oxygen cylinders, missing electrical panel covers, non-functioning exhaust ventilation, lack of privacy curtains in bathrooms, improperly mounted hand grips, exit doors requiring two hand motions to open, fall hazards outside the building, improperly charged fire extinguishers, and an incorrectly oriented evacuation plan.
Deficiencies (21)
| Description |
|---|
| Corridor doors did not positively latch closed as required, allowing smoke passage. |
| Receptacle covers removed in room 26, leaving exposed energized surfaces accessible to residents. |
| Toilet in women's bathroom near nurse station loosely mounted, causing potential fall hazard. |
| One-hour fire rated walls and ceilings compromised with unsealed holes and penetrations in multiple locations. |
| Cross-corridor smoke barrier doors failed to latch closed when activated by fire alarm. |
| Motorized smoke and fire damper protecting duct penetration through attic smoke barrier wall failed. |
| Corridor door to Business office held open by mechanical device preventing proper closing and latching. |
| Fire rated door to attic from furnace room would not latch. |
| Kitchen door prevented from latching; latching hardware and latch strike removed; door tied open. |
| Exterior dryer vents partially clogged with lint, posing fire hazard. |
| Portable medical oxygen cylinders stored in unapproved milk crate in room 24. |
| Missing blank covers in electrical panels in kitchen and basement exposing energized parts. |
| Ice machine drain line extended into floor drain, risking contamination. |
| Electrical disconnect at range in activity room lacked locking feature, allowing unsupervised use. |
| Exhaust ventilation not working in multiple bathrooms, laundry, and mop sink area. |
| No privacy curtain provided at tub accessible on two sides in bathroom with multiple fixtures. |
| Hand grip loosely mounted at toilet in central bath on west side, risking resident falls. |
| Several exit doors require two hand motions to open, violating single hand motion requirement. |
| Small trench approximately 5 inches deep adjacent to sidewalk at rear left side of building presents fall hazard. |
| Fire extinguisher in attic furnace room on west side needs recharging. |
| Evacuation plan on East Hall oriented incorrectly relative to building layout. |
Report Facts
Licensed bed capacity: 49
Depth of trench: 5
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