Facility Evaluation Report

On 07/19/23, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct

Required Annual Inspection. LPA was greeted by receptionist and stated the purpose of the visit. LPA met with Executive Director (ED) Irma Langston and Memory Care Director Don Marchel. LPA conducted tour of facility with ED. Residents were observed walking around the facility and in common areas.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway

obstructions or fire hazards. Fire extinguisher was observed with a service date of:12/14/22. Last fire drill completed on 06/15/23.

Common area and Kitchen was toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in walk-in freezer, walk-in refrigerator, and pantry. Food is delivered twice a week. Refrigerator temperature was maintained at 37 degree F. and freezer was maintained at -7 degree F.

LPA toured a sample of resident bedrooms. Residents' rooms were toured and observed with adequately furnished with bed, dresser, and adequate lighting. Hot water temperature tested at between 108.7 degrees F. to 108.9 degrees F. LPA observed securely fastened grab bars and non-skid mat in all shower areas.

Medications were stored in a locked medication room in a medication cart. MARs and medications were

reviewed. First Aid Kit was stored in medication room and observed with all required items. Adequate PPE supplies was observed. LPA toured activity room and laundry room.

Facility courtyard was toured and observed to be free from debris. There was outdoor seating available for the residents.