Facility Evaluation Report

Licensing Program Analysts (LPA)'s Vadim Gorban and Shawna Doucette arrived at the facility unannounced to conduct a Required Annual Inspection. LPA's were granted entry by receptionist. Staff contacted Administrator Joy Carter via telephone who responded to assist with the visit.

LPA's toured the facility. Residents' apartments were toured and inspected and observed to be clean. Hot water temperature was measured at 147.4 F in memory care. LPA's observed residents to be participating in activities. LPA's did not observe resident rights or CCLD poster posted in the facility. LPA's observed the hall on floor 6 to be under construction.

Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked Medication cart and in a locked medication room. Cleaning supplies were in a locked storage closet. Facility has a pull station fire alarm and a fire panel and sprinkler system. Fire extinguishers were charged and had service dates of 9/15/25. Fire drill was last conducted 1/22/26.

There was outdoor seating for the residents. Resident records, medication and staff records were reviewed. R5's care plan indicated care staff are providing wound care. Staff did not have training for residents on hospice. R5 is listed to be bedridden. Facility does not have a bedridden plan in plan of operation and is not fire cleared to retain a bedridden resident. R6 does not have an admissions agreement. R2 does not have a medical assessment signed by a skilled professional. R2 did not have a reappraisal after R2's condition changed. Current first aid and CPR were on file for staff.

Exit interview conducted, report signed and copy of this report with appeal rights provide to administrator for facility records.