Facility Evaluation Report

On 08/28/2025 at 10:00 AM, Licensing Program Analysts (LPAs) Ardalan Gharachorlo and David Doidge arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Executive Director, Ezekiel Griffin and explained the purpose of the visit.

LPAs toured the facility including but not limited to 2 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 73 degrees F. The hot water temperature in a residents bathroom was measured at 112 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 01/16/2025. Emergency Disaster Plan was last posted on 08/28/2025. First aid kit was observed to be complete. Emergency disaster drills are conducted quarterly, last conducted on 07/30/2025.

LPAs reviewed 5 residents records and 5 staff records, and all were complete. LPAs also reviewed a sample of resident’s medications. The following documents were reviewed during the visit:LIC 500 Personnel Report

,LIC 610E Emergency Disaster Plan, Liability Insurance, Current Administrator’s Certificate

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.