Facility Evaluation Report

Licensing Program Analyst (LPA) J. Duarte and Licensing Program Manager (LPM) A. Walton, arrived unannounced to conduct the Annual Inspection. LPA and LPM met with and explained the reason for the visit with Administrator (AD) Crystianna Robinson.

During this visit, LPAs toured the facility inside and out. Resident rooms were observed to have required furnishings and adequate lighting. LPAs observed required items in bathrooms to include shower mats and grab bars. The hot water in resident bedrooms measured between 107 and 110 degrees F. Multiple resident rooms were observed to have stained carpet, dirty toilets, and a strong urine odor.

The kitchen was toured. LPAs observed a two-day supply of perishable and a seven-day supply of nonperishable food, emergency food, water, and paper products. Refrigerator, freezers, prep stations and appliances were organized with food properly stored and labeled. The kitchen area was observed to have dead water bugs.

Medications are centrally stored in locked medication carts in a medication room. Doors and passageways are unobstructed throughout the facility.

LPAs toured the outdoors to find the grounds well-kept with clear walkways, and seating available. The in ground pool was gated and locked as required. The facility utilizes delayed egress in memory care; however, the facility does not have fire clearance for delayed egress. The fenced patio in memory care has an exit; however, the exit was secured closed with a padlock. Fire extinguishers were serviced on 09/26/2025. A fire drill was conducted on 03/04/2026, per staff records.