Facility Evaluation Report

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 10:16 AM. LPA met with facility staff who contacted the facility Administrator Annie Osborn via telephone call. The facility Administrator arrived to the facility at 11:01 AM. Entrance interview was conducted and the reason for the visit was explained.

Beginning at 11:03 AM, the LPA, along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and that facility is in compliance with Title 22 Regulations. The following was observed:

COMMON AREAS : This included the living room and dining room. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contained an appropriately screened fireplace, a television, and activities for resident use. The dining room was observed to be clean and contained adequate seating for resident use. Smoke detectors, fire doors, and carbon monoxide detectors were tested at 03:46 PM. During the test LPA observed the fire doors leading to resident bedrooms to fail to close when the fire alarm in the living room was activated. LPA tested the fire alarms in the kitchen and entryway and observed the fire doors closing properly. LPA retested the fire alarm in the living room at 03:48 PM and again at 03:52 PM and again observed the fire doors to fail to close. LPA notified the Administrator that the failure for the fire doors to close when the living room fire alarm was activated constituted a violation of the facility’s fire clearance. LPA notified the Administrator that this is a zero-tolerance violation and a civil penalty in the amount of $500 is being assessed on today’s date (08/03/2026).