Facility Evaluation Report

Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required- 1 year visit. LPA met with Executive Director Pam Ogot and LPA explained the purpose of the visit. Executive Director helped assist the LPA with the inspection. Facility is licensed for 45 non-ambulatory, maximum of (8) hospice residents and (4) bedridden residents ages 60 and over. Currently, there are (40) residents in the facility who are 60 years and older, of which no residents are bedridden and two (2) are receiving hospice care.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. The facility has an Infection Control Plan. Staff are adhering to infection control requirements. Emergency and disaster plan was completed and up to date. Infection control practices and Personal Protective Equipment (PPEs) were maintained.

Operational Requirements: The Infection Control Plan has been added to the Plan. Facility accepts and retains residents with dementia. Approved Dementia Care Plan is in their plan of operation. There is no separate memory care unit inside the facility. Facility is approved for (8) hospice residents. Liability Insurance is in place. Surety bond is in place. Fire drill was last conducted on 02/20/2026. Disaster drill was last conducted on 02/20/2026.

Physical Plant/Environment Safety: LPA along with Executive Director toured the facility. The facility is a 2-story building located in a residential community. The grounds in the facility are well landscaped and have a leveled walkway to the entrance of the building. The facility consists of: First floor: Lobby, Administrative offices,