Facility Evaluation Report

Licensing Program Analysts (LPAs) Samer Haddadin Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPAs were greeted and granted entry by the Concierge. During today’s visit, LPAs met with Tonya Reynolds Executive Director (ED) .

The facility consists of two buildings which has a capacity of 200 with an approved fire clearance of 173 non-ambulatory residents of which ten may be bedridden and a hospice waiver for twenty. The facility currently has a census of 137 residents in care with 95 residents in the three-story, Independent/ Assisted Living building and 42 residents in the Villagio building; which is Memory Care.

During today’s visit, LPAs toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in six of six resident bathrooms, and testing auditory devices on all exits . The hot water temperature measured between 110.8 to 118.9 degrees Fahrenheit and all smoke and carbon monoxide detectors were operational and were tested on March 1, 2025 by an outside vendor. The fire extinguishers are charged and were serviced on March 27, 2025.. LPAs inspected the kitchen with the Executive Chef and observed a minimum of two days perishables and seven days nom-perishable food on hand. LPAs walked through refrigerator and freezers and both units were at the required temperatures.

LPAs toured the Villagio building and the delayed egress was in working order. LPAs observed residents in activities and other residents relaxing after breakfast in both the upstairs and downstairs dining rooms. ED toured LPAs outdoors and the walking path was free of obstruction. There were koi ponds, a bridge and a locked pool area with various shaded seating areas. LPAs also observed a fenced dog area and observed (Continued on LIC 9099-C)