Facility Evaluation Report

On 8/19/2025, Licensing Program Analyst Arvin Villanueva (LPA) arrived unannounced at this facility to conduct their annual inspection visit. LPA met with Executive Director/Administrator, Karly Sturgeon (S1), and stated the purpose of the visit.

Overview : Facility is licensed to serve up to 49 elderly residents, 24 are ambulatory and 22 are non-ambulatory. Facility has bedridden clearance for 3 residents. Facility has a hospice waiver for 10 residents.

Physical Inspection : Areas inspected include, but not limited to, the kitchen, resident bedrooms, resident bathrooms, common areas and outdoor areas. LPA inspected 3 resident bedrooms and 3 resident bathrooms. LPA measured the hot water temperature in the 1 of 3 bathrooms to be at 111 degrees Fahrenheit. Fire extinguisher were observed throughout in the hallways and were inspected on 6/24/2025. Smoke and carbon monoxide detectors were also observed throughout.

Medication room was observed to be inaccessible to residents in care. Kitchen area was observed and is also inaccessible to residents in care.

Outdoor area was inspected including fence, gates, ramps and emergency walkways.

Record Reviews: Review of 3 of 3 resident files include review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status.

Review of 5 staff files include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training.

LPAs also reviewed fire drill/disaster drill records; facility conducts quarterly drills. Last drill was on 6/24/25.

LPAs was requested a copy of current Liability Insurance Certificate, LIC500 and LIC308 to be submitted to the Department.