Facility Evaluation Report

On 7/21/26 at 11:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director (ED), Mary Goldhoff and explained the purpose of the visit. The facility’s fire clearance was approved for all may be non-ambulatory with 5 bedridden.

LPA toured the facility with ED including but not limited to random residents apartments, bathrooms, multiple activity rooms, 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 72 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 were measured between 105.0-120.0 degrees Fahrenheit. Freezer measured at 0 degrees Fahrenheit and refrigerator measured at 30 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.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 12/8/2025. Emergency Disaster Plan was last posted on 6/2/2026. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 5/23/2026

LPA reviewed 5 residents records. LPA reviewed 5 staff records. LPA reviewed a sample of resident’s medications.

Updated copies of the following documents were requested for facility file and are to be mail to CCL by 8/1/2026:

LIC 308 Designation of Administrative Responsibility

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