Facility Evaluation Report

On November 26, 2025, Licensing Program Analysts (LPAs) Eboni Bentley and Jenifer Tirre conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPAs introduced self and was granted entry into the facility by staff, after stating the purpose of the visit. Executive Director/Administrator (ED) Sarah DeVore arrived at the facility and remained to assist during the visit.

The facility is a five-level structure licensed to operate for 164 non-ambulatory residents with a hospice waiver for 25. LPAs observed residents in care and conducted interviews.

During the visit, LPAs toured inside and outside of the physical plant with staff. There were no bodies of water or obstructions on the premises. Ten resident rooms and all common areas were inspected. Beds and bedding supplies were in good condition and adequate lighting was provided. Bathrooms were found to be clean and operational. Water temperature in ten out of ten resident bathrooms measured between 111.2 degrees F to 119.6 degrees F.

LPAs observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two day supply of perishable and seven day supply of non-perishable food available and maintained properly. LPAs toured the patio and observed shaded seating areas with a table and chairs for residents to sit outside.

No Deficiencies are being cited during today's visit. An annual continuation will follow.An exit interview was conducted, and a copy of this report was provided to Executive Director/Administrator Sarah DeVore at exit.