Facility Evaluation Report

On 4/15/2026 at 9:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Business Office Director, Kristy Andrews and explained the purpose of the visit. The facility’s fire clearance was approved for all may be non-ambulatory and 15 bedridden.

LPA toured the facility with Maintenance including but not limited to residents apartments, bathrooms, activity room, kitchen, common area and courtyard. 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 at 73 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom measured between 105-120 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.

Fire extinguisher was last serviced on 2/2/2026. First aid kit was observed to be complete. Emergency disaster drill completed 2/24/2026. Emergency Disaster plan reviewed 3/9/2026

LPA reviewed 5 residents records. LPA reviewed 5 staff records LPA advised facility to complete first aid training/ CPR for all required staff through such agencies as the American Red Cross and all staff were associated to the facility.

Updated copies of the following documents were requested for facility file and are to be mailed to CCL by 4/20/2026:

LIC 308 Designation of Administrative Responsibility

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