Facility Evaluation Report

On 1/22/2026 at 9:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director (ED), Jennifer Coons and explained the purpose of the visit. The facility’s fire clearance was approved for 176 non-ambulatory of which 100 may be bedridden.

LPA toured the facility with ED including but not limited to 7 residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. Pool observed locked with an appropriate gate. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 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’ bathrooms were measured at 109, 116.8, 116.6,107.5, and 116.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid flooring. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Freezer temperature measured at -1 degrees Fahrenheit and refrigerator at 39 degrees Fahrenheit. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care.

LPA reviewed 6 residents records. LPA reviewed 5 staff records and 5 of 5 are associated to the facility. LPA reviewed a sample of resident’s medications. LPA observed that at least 1 person on each shift has a valid CPR certificate.