Facility Evaluation Report

At approximately 9:10AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year Visit and met with Director of Nursing, Bridget Geist, and Director of Staff Development, Justin Salter. Administrator, Karina Tapia, was unavailable during visit. Facility is a Continuing Care Retirement Community (CCRC) and has a portion of the property licensed as a Residential Care Facility for the Elderly (RCFE). This portion of the property provides care and assistance for Older Adults in Assisted Living. Facility has an approved fire clearance and capacity for 28 Non-Ambulatory or Bedridden Residents. Facility has a Hospice Waiver for 5 individuals. Upon arrival, LPA was informed that there were currently 17 residents in care in Assisted Living and 3 staff members on-site.

LPA reviewed the Facility's Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of the facility with Director of Staff Development and observed the following: 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. 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. Hot water temperatures for a sample size of 4 sinks were found to be out of compliance with Title 22 regulations of 105 to 120 degrees Fahrenheit, measuring at 121.8F, 121.2F, 124.8F, and 123.0F. Facility was observed to have emergency evacuation chairs at their stairwells.

Facility fire extinguishers were last inspected June 2026. Smoke and carbon monoxide detectors are hardwired and were last inspected July 2026. Facility's sprinkler and fire system were last inspected February and May 2026. Facility's last emergency/disaster drill was conducted July 2026. Facility was observed to have an adequate supply of emergency water accessible in the event they needed to shelter in place for 72 hours.