Facility Evaluation Report

At approximately 8:55AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Executive Director, Tracy Freudendahl, Interim Resident Care Director, Elvira Suciu, and Resident Care Director, Isabel Saunduvs . Facility serves older adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Facility has a total capacity for 160 residents and an approved fire clearance for 130 non-ambulatory residents, of which 40 residents can be bedridden. Facility has an approved hospice waiver for 20 individuals. Upon arrival, LPA was informed that there were 116 Residents in care and 35 staff members on-site.

LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of the facility with Interim Resident Care Director and Resident Care Director and observed the following: Facility is a 3-story building for Assisted Living and Memory Care. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file. Emergency evacuation chairs were observed at facility stairwells. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations.

There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for a sample size of 12 sinks were found to be within Title 22 Regulations of 105 to 120 degrees Fahrenheit. Facility's fire extinguishers were last inspected November 2025. Facility's fire and sprinkler system was last inspected April 2026. Facility's emergency disaster plan was last reviewed and updated on 03/18/2026. During walkthrough, LPA observed multiple instances of expired food in the facility's art and crafts room. LPA, Interim Resident Care Director, and Resident Care Director, disposed of all items. LPA also observed over the counter (OTC) medications in two resident rooms.