Facility Evaluation Report

On 07/14/26, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct the Required Annual Inspection. LPA introduce self, stated the purpose of the visit, and met with Administrator Karen Dhaliwal. LPA toured facility with Administrator.

The facility was observed to be at a comfortable temperature at 73 degrees F, clean, in good repair, and no passageway obstructions or fire hazards. Last fire drill was completed on 6/29/26. Kitchen was toured. An adequate supply of perishable and non-perishable food was observed to be properly stored. Temperature was maintained at 33 degree F. in stand up refrigerator and stand up freezer temperature was maintained at -2 degree F. Fire extinguisher was observed throughout facility with a service date of: 06/13/25. Medications were stored and locked in medication carts.

MARs and Centrally Stored Medication List were reviewed. Medications were checked.

LPA toured a sample of residents’ room were toured and observed with adequately furnished with bed, dresser, and adequate lighting. Bathrooms were toured and observed with securely fastened grab bars. Hot water temperature was tested and maintained at 111.7 degree F in room 401. 115.5 degree F in room 409. 112.4 degree F in room 303, 113.2 degree F in room 301. 111.7 degree F in room 201. 111.8 degree F in room 206, and 111.7 degree F in shower room.

Chemicals were stored and locked in housekeeping closet. Washer and dryer observed operational and functioning during visit. Extra linens observed. 30-second delay egress was observed.