Facility Evaluation Report

On 08/08/2025 at 9:15AM, Licensing Program Analysts (LPAs) Andrew Christy and Yasamin Brown arrived unannounced to conduct the Required 1 Year Annual inspection. LPAs met Executive Director Kim Sor and explained the purpose of the visit. The facility currently houses 95 residents with a capacity of 121 residents..

LPAs toured the facility with executive director including, but not limited to, 5 residents’ apartments, activity rooms, kitchen, common areas, and courtyard. LPAs observed that lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 75.0 degrees Fahrenheit. The hot water temperature in a sample of residents' bathrooms were measured at 109.8, 112.8, & 107.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medications and sharps are locked and inaccessible to residents. First Aid kit was found to be complete.

Fire extinguishers were last serviced on 07/04/2025. Emergency Disaster Plan last updated 07/29/2025. Fire drills were last conducted 05/27/2025. LPAs reviewed 5 staff files, all found to be complete and up to date. LPAs also reviewed 5 resident files, all found to be complete and up to date. MARs and medications for 5 residents were also reviewed and no errors were found.

No deficiencies found during visit. Exit interview conducted and a copy of this report was made available to the executive director.