Ingleside Park

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon conducted a 1 year Annual visit to the facility above. LPA met with Nikole Daugherty, Back up Administrator and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, and hand soap. The facility has EPA approved disinfectant spray and cleaners. The facility has a 30-day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE) upon hire and annually thereafter. Physical Plant & Environmental Safety: LPA toured 10 resident room and 2 have 1/2 baths on suite, 3 common area restrooms and 2 outside cottages with shared a bathroom. The fire extinguisher were charged and tagged on 11/10/2025. LPA was authorized to enter and inspect facility. The facility has dual smoke and carbon monoxide detectors hard wired with sprinkler system. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care and stored in locked storage room. The facility has sufficient space inside and outside for activities and visiting. The facility has a patio with furniture, walkways and shaded areas for resident use. The facility is completely fenced around the back and side yards with pull up gate latches that are self closing and self latching. The facility has telephone and internet service for resident use. Continued 809-C Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 06/16/2027. The facility is approved for a capacity of 15. The fire clearance is granted for up to 15 bedridden residents. Hospice is approved for 7. Staffing: The facility currently employes 12 staff, and 2 Administrators. Staff records are kept confidential. Five staff files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, and fingerprint clearance or exemptions. Personnel Records & Training: The facility keeps confidential files for each staff member. Five Staff files reviewed had initial 40 hours of training or annual training completed for 20 plus hours from 07/2025-06/2026. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for signed Admission Agreements, Safeguard for property and valuables, LIC. 602A Physicians report, Appraisals Needs and Services Plan, and Emergency and ID forms. The facility does not keep cash resources on any residents in care. Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies. The facility has an emergency food and water supply. Incidental Medical Services: Facility provides assistance in arranging transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed 9 residents’ medications, no labels were altered, no medications were expired and all medications were kept in their original containers. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. Emergency exits and telephone numbers were posted. Keys and Codes are available for staff on all shifts to access full facility in an emergency. Disaster plan reviewed and is signed off annually by Administrator. Residents with Special Health Needs: The facility does accept dementia residents in care, all sharps, knives, cleaning products and items that can pose a hazard are locked in storage rooms. The facility currently has 1 resident on oxygen, signs are posted. The facility 2 current resident on hospice services. The facility currently has 1 residents on home health services. Hospice and Home Health Plans are kept up to date and on file at the facility. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Jun 29, 2026

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) De Leon conducted a Case Management Continuation Annual visit to the facility above. LPA met with Nikole Daugherty, Administrator and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, and hand soap. The facility has EPA approved disinfectant spray and cleaners. The facility has a 30-day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). Physical Plant & Environmental Safety: LPA toured 8 resident room and 3 on suite restrooms, 3 common area restrooms and 2 outside cottages with shared a bathroom. The fire extinguisher were charged and tagged on 11/20/2024. LPA was authorized to enter and inspect facility. The facility has dual smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats or textured bottoms. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care and stored in locked storage room. The facility has sufficient space inside and outside for activities and visiting. The facility has a patio with furniture, walkways and shaded areas for resident use. The facility is completely fenced with pull up gate latches that are self closing and self latching. The facility has telephone and internet service for resident use. Continued 809-C Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 06/16/2026. The facility is approved for a capacity of 15. The fire clearance is granted for up to 15 bedridden residents. Hospice is approved for 7. Staffing: The facility currently employes 10 staff, and 2 Administrators. Staff records are kept confidential. Five staff files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, and fingerprint clearance or exemptions. Personnel Records & Training: The facility keeps confidential files for each staff member. Five Staff files reviewed had annual training completed for 20 plus hours from 09/2024-08/2025. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for signed Admission Agreements, Safeguard for property and valuables, LIC. 602A Physicians report, Appraisals Needs and Services Plan, and Emergency and ID forms. The facility does not keep cash resources on any residents in care. Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables and plenty extra, to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies. The facility has an emergency food and water supply. Incidental Medical Services: Facility provides assistance in arranging transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed residents’ medications, no labels were altered, no medications were expired and all medications were kept in their original containers. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. Emergency exits and telephone numbers were posted. Keys and Codes are available for staff on all shifts to access full facility in an emergency. Disaster plan reviewed and is signed off annually by Administrator. Continued 809-C Residents with Special Health Needs: The facility does accept dementia residents in care, all sharps, knives, cleaning products and items that can pose a hazard are locked in storage rooms. The facility currently does not have any residents oxygen. The facility 1 current resident on hospice services. The facility currently has 2 residents on home health services. Hospice and Home Health Plans are kept up to date and on file at the facility. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Aug 7, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at 9:30 am to conduct a 1 year annual visit to the facility above. LPA met with Administrator Nikole Daugherty and explained the purpose of the visit. Staffing: The facility currently employes 10 staff, and 2 Administrators. Staff records are kept confidential. Five staff files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, and fingerprint clearance or exemptions. Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for 20 plus hours from 06/2024-06/2025. LPA will need additional time to complete the annual visit and will return at a later date. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Jun 19, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rankin made an unannounced 1-year required annual visit to the facility above. LPA met with Janet Johnson, House Manager, and Nikole Daugherty, Administrator, and explained the purpose of the visit. LPA requested a staff roster, a resident roster, emergency and disaster plan, and documentation of quarterly emergency drills. Documentation of quarterly emergency drills show they are done quarterly on various emergency events. LPA toured the facility with the Administrator and the following was noted: LPA observed the license posted, licensing reports, personal rights, non-discrimination notice, LTCO poster, CDSS Complaint Poster, Bill of Rights and Right to Residential Council. The facility has 10 bedrooms and 6 bathrooms, a kitchen, dining room, living room, courtyard in the front and back of the facility, and storage garage. Medications are kept in a locked room next to the kitchen. Physical plant was checked for cleanliness and condition. Walls, windows, ceilings, floors, floor coverings, and doors were checked, and all were in good condition. The facility maintains a comfortable temperature. The facility provides a working telephone for resident use. Smoke and carbon monoxide detectors are operational. Fire extinguishers (2) are located in the hall by room 1 and in the medication room and were last inspected 12/2023 and are charged in the green. There are no issues with Fire Clearance. LPA observed all chemicals are locked and inaccessible. The facility has cameras inside and outside throughout the facility, signed waivers were in all residents files reviewed. Continued on 809-C. Living and dining room furniture were also checked for functionality and condition. The living room and dining room are clean, safe and sanitary. Courtyard of the facility has outdoor furniture, with a covered shaded area for residents in the back yard. There are no bodies of water on the premises. There is plenty of outdoor lighting available for the safety of the residents. External gates have latches and working properly. Kitchen was sufficiently stocked with two-day perishable and seven-day non-perishables. The menu was posted for review. Snacks and beverages are available for residents in the facility when they want. Foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. The refrigerator and freezer were in compliance with temperatures. Resident rooms have beds with sheets, pillowcase, mattress pad, and blankets which are in good condition. There is at least one chair, nightstand, and enough lighting for each resident. There is enough linen available to change weekly or more if need. Bathrooms were checked for cleanliness and proper operation. Residents have a sufficient number of supplies for personal hygiene. Soap, paper towels and toilet paper are provided by the Licensee. Grab bars are secured in toilet and shower areas. Showers have non-slip mats. Resident records were reviewed for requirements and legibility: LPA reviewed 4 residents’ files for current Medical Assessments with TB results, Current Appraisal Needs and Service plans, and signed Admission Agreements. Planned activities are offered to residents in care. Staff records were checked for expired or missing certificates and clearances: LPA conducted a file review of 4 staff for criminal record clearances/associations, Health screening with TB results, current First Aid/CPR, and annual training requirements. Continued on 9099-C Training is assigned by administrator via Relias to ensure annual requirements are completed and tracked. Medications are in a centrally stored and locked room next to the kitchen, including over-the-counter medicines. Medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the residents’ doctor. Proper medication dispensing instructions are followed. Exit interview conducted, and the report given.the state’s words, verbatim · CDSS document, Jun 19, 2024

The state marks this report as 11 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.