Facility Evaluation Report

On July 17, 2025, Licensing Program Analyst Samer Haddadin conducted an unannounced annual inspection of the facility. Upon arrival, LPA Haddadin was greeted by Administrator Troy Byington, who granted entry and was advised of the purpose of the visit. Together, they toured both the interior and exterior of the three-story building, which houses a delayed-egress memory care unit, a commercial kitchen and large dining room, a medication room, multiple common areas and storage rooms, and two courtyards—one central and one dedicated to memory care—that offer shaded seating and ample space for resident activities.

The facility contains 115 resident rooms, and the census at the time of inspection was 107 residents. During the visit, five residents were observed in their individual rooms, each of which was furnished with a bed, a chair, and clean linens, provided adequate storage, and was free of tripping hazards. Outdoor areas, including both courtyards, were well maintained: furnishings were in good repair, pathways were clear of hazards, and the grounds appeared safe and inviting.

All safety equipment was current. The fire alarm system is maintained by a third-party contractor, with its most recent inspection completed on March 11, 2025. Fire Master serviced the extinguishers on June 2, 2025, and service tags indicate a prior inspection date of September 10, 2024. Hot water temperature was measured at 105.9°F, meeting regulatory requirements.

The facility maintains sufficient food supplies, with at least a two-day cache of perishables and a seven-day cache of non-perishables. The kitchen was observed to be in good repair, and all major appliances were operational. Cleaning supplies were stored securely in the third-floor maintenance room, ensuring they remain inaccessible to residents.