Facility Evaluation Report

On 12/2/2025 at 12:30PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Ana Breen and explained the purpose of the visit. The facility’s fire clearance was approved for all may be non-ambulatory with a hospice waiver for 3.

LPA toured the facility with Administrator including but not limited to residents rooms, bathrooms, multiple activity rooms, kitchen, common area and backyard. 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 77 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ bathrooms were 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. Sharps and toxic are locked and inaccessible to residents in care.

Smoke detectors and carbon monoxide dectector were in operating condition during visit. Fire extinguisher was last serviced on 10/14/2025. Emergency Disaster Plan was last posted on 3/8/2025. First aid kit was observed to be complete. Emergency disaster drill was last conducted in September 2025.

At 1:30 pm, LPA reviewed 5 residents records. At 2:00pm, LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility.