Facility Evaluation Report

On 05/21/2025 at 9:45 AM, Licensing Program Analysts (LPAs) P. Manalo and K. Nguyen arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Executive Director, Connie Kuhlmann and explained the purpose of the visit. The facility’s fire clearance was approved for 160 residents all may be non-ambulatory and 15 hospice and total care waivers.

LPAs toured the facility inside and out including but not limited to 7 residents' apartments, bathrooms, multiple activity rooms, kitchen, and dining hall. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained between 72 to 74 degrees F all around the facility. The hot water temperature in sample of residents’ shared bathroom were measured at 116.9, 114, 112.7, 109, 108.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid shower pan.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 05/15/2025. Emergency Disaster Plan was last posted on 03/05/2025. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 04/25/2025.

At 11:52 AM, LPAs reviewed 7 residents records. At 12:20 PM, LPAs reviewed 6 staff records and 5 of 6 have current first aid training and 6 of 6 associated to the facility. At 2:30 PM, LPAs reviewed two sample of resident’s medications.