Facility Evaluation Report

On 8/14/2025 at 9:30 AM, Licensing Program Analysts (LPAs) L. Alexander and Y. Brown arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with, Care Specialist, Kelley Jeffries, and explained the purpose of the visit. Assistant Executive Director, Deborah Bradley and Interim Executive Director Ricardo Romero were in a meeting but joined after an hour. The facility’s fire clearance was approved for two-hundred (200) non-ambulatory. Hospice waiver approved for twenty (20).

LPAs toured the facility with Deborah including but not limited to six (6) residents’ apartments, two (2) models, bathrooms, multiple activity rooms, kitchen, common area and outside courtyard. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 74 degrees F. The hot water temperature in a sample of residents’ shared bathroom were measured at 132, 135, 137 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. Emergency fire drill was last conducted on 08/3/2025. Emergency disaster plan was last updated 08/01/2025.