Facility Evaluation Report

On 06/16/2026 at 9:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Rachael Davis and explained the purpose of the visit. The facility's fire clearance was approved for all may be non-ambulatory of which 8 may be bedridden.

LPA toured the facility with Executive Director including but not limited to random 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 75 degrees F. The hot water temperature in a sample of residents’ shared bathroom were measured between 106.8-113.2 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. The freezer temperature measured at 0 degrees F and the refrigerator 40 degrees F.

Fire extinguisher was last serviced on 2/10/2026. Disaster Drill was last conducted 5/26/2026. Emergency Disaster plan last reviewed 5/1/2026. Smoke detectors and sprinklers are interconnected and observed throughout facility. First aid kit observed complete.

LPA reviewed 6 staff records and 6 of 6 are associated and have current first-aid training. LPA reviewed 5 residents records .

Updated copies of the following documents were requested for facility file and are to be mailed to CCL by 7/1/2026:

LIC 308 Designation of Administrative Responsibility

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