Facility Evaluation Report

On 09/26/2025 at 12:30PM, Licensing Program Analysts (LPAs) James Sampair and Andrew Christy arrived unannounced to conduct the Required Annual Inspection of the facility. Upon arrival, LPAs stated the purpose of the visit to Administrator Rachelle Santiago. The facility is currently at capacity with six (6) residents.

LPAs inspected the interior and exterior of the facility, including the kitchen, dining area, restrooms, community living spaces, resident rooms, storage areas, and the grounds of the facility. More than the required minimum of 7 days of nonperishable and 2 days of perishable foods were appropriately stored. Temperature in the dining room was measured at 75.0 degrees Fahrenheit. Fire extinguisher was fully charged and last replaced on 07/09/2025.

The carbon monoxide and smoke detector were fully operational. The LPAs observed postings in the facility that included a complaint poster, Ombudsman and Personal Rights posters, Theft and Loss Policy, Rights to Resident Council, and Rights to Family Council. The LPAs reviewed facility records, records of 5 staff members, and records of 5 residents, all found to be complete. The Emergency Disaster Plan was last reviewed 06/18/2025. Quarterly emergency drills were last ran 09/05/2025.

The following deficiency was cited during the annual visit:

The hot water in the resident's bathroom measured in ranges of 126.7-129.6 degrees Fahrenheit.

Further information on the citation can be found on form LIC809D. Exit interview conducted and a copy of this report, along with appeal rights, was made available.