Facility Evaluation Report

Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. There are currently 31 residents in care. Facility approved/cleared for 62 non-ambulatory and hospice waiver for 16.

LPA and Administrator toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Facility has a board of residents with modified diets for kitchen staff to be aware.

During tour LPA observed residents interacting in a daily morning stretching routine. Facility has daily activities scheduled throughout the day for residents to participate. Facility has a generator surrounded by secured fencing. All rooms were furnished per regulation. All rooms were in good repair. LPA and administrator observed feces smeared on a common chair outside a residents room (Technical Violation). Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care were measured at 109.4, 126.3, 108.3 and 109.9 degrees F, administrator turned down the water heater near the room reading 126.3 degrees F. Fire extinguishers were last inspected October 2025. Facility has a 5 year testing for auto sprinkler system that was tested by the State Fire Marshall on 04/07/2023. Facility has emergency supplies located in a hallway closet. Medications were found to be centrally stored. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record.

Facility conducts quarterly emergency disaster drills, with the last one being conducted 12/08/2025.