Facility Evaluation Report

Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced annual inspection on 10/13/25 using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with Staff, Nancy Mandic, who provided the tour of the facility. The assistant administrator, Meagan Swan, arrived later to assist with the rest of the inspection.

The facility is licensed to serve 66 residents, of which (26) may be non-ambulatory and (40) bedridden. There is a hospice waiver approved for (15) residents. The licensed part of the campus consists of (3) cottages called The Hearth, Stewart Cottage, and The Ranch House (Memory Care unit). The Commons building consists of the dining area and kitchen. The liability insurance is maintained at a $1 million for each occurrence and $3 million in total general aggregate.

LPA observed the following during the visit today:

The Commons building is comprised of a library area, mail room, business offices, dining room, an outdoor dining area, and a commercial kitchen. The food preparation areas were clean. There was adequate supplies of both perishables and nonperishable items. The cleaning supplies are kept in away from the food area.

The Hearth building is comprised of resident rooms, activity room, a laundry room, and the medication room. LPA selected (3) rooms (rooms #8, #13, and #15) to inspect. The bathrooms have skid mats, grab bars, and the water temperature was within the required range.

Stewart Cottage is comprised of resident rooms, activity room, two family rooms, a shower room, medication room, and a few offices. LPA selected (3) rooms (rooms #4, #7, #12) to inspect. The bathrooms have skid mats and the water temperature was measured within range.