Facility Evaluation Report

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by the Receptionist. During today’s visit, LPA met with Danny Vera, Executive Director (ED).

The facility is a two story building with an approved fire clearance of one-hundred four non-ambulatory residents; of which six may be bedridden . The facility currently has a census of seventy-eight residents in care. The facility is approved for a hospice waiver of twenty residents and there are five residents receiving hospice services.

During today’s visit, LPA toured the facility with ED Vera and inspected the physical plant, including but not limited to testing all smoke detectors and testing hot water temperatures in four of four resident bathrooms . The hot water temperatures measured between 109.4 and 113.7 degrees Fahrenheit. LPA tested a resident bathroom pull cord and staff responded under five minutes. Resident bathrooms had non-skid mats and grab bars. All smoke detectors were operational and tested on November 4, 2024 by an outside vendor. A fire system alarm inspection is scheduled for May 2025. The fire extinguishers were charged and were serviced on April 8, 2025. The facility’s last fire drill was conducted on February 12, 2025 .

LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand . LPA toured the kitchen and observed resident modified diets posted for line staff. Freezer and refrigerators were at the proper temperatures. Residents were observed in the dining room at 11:30am and had complimentary things to say about the lunch entree of the day.