Facility Evaluation Report

On April 22, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced for the purposes of conducting a required 1-Year annual inspection. LPA was greeted and granted entry after explaining the purpose of the visit to staff. Executive Director (ED) Mandy Taylor arrived at approximately 9am to assist with the annual inspection.

The facility is licensed to provide services to residents age range 60 and over, (220) non-ambulatory, of which 20 may be bedridden. Non-ambulatory is on the first and second floor and 50% of third floor. Approved for delayed egress, with a hospice waiver for 40 residents. During the inspection, LPA conducted a tour of the facility with ED Taylor and the following was observed: All common areas were inspected along with 20 resident apartment, which had all the required elements. The residents’ personal bathrooms were observed operational, grab bars were secure and the hot water temperatures in 16 out of 20 resident bathrooms measured between 116.2 and 119.5 degrees Fahrenheit. LPA advised staff to monitor water temperatures on a weekly basis to ensure temperatures do not exceed 120 degrees Fahrenheit. LPA inspected the kitchen and the dining areas, and toured the outside grounds of the facility. All walkways were clear of hazards and there was ample seating with outdoor shade available for the residents. The smoke alarms and carbon monoxide detectors were last tested on November 25, 2025 per the fire alarm inspection report conducted by Tricom Fire & Electric Co. Evacuation chairs were observed at the top of each stairwell. There were several fire extinguishers mounted throughout the facility, fully charged, and serviced on September 22, 2025. Interviews were conducted with 20 residents and 4 staff during today's visit.

Due to time constraints, an annual continuation visit is needed and ED was advised that deficiencies may be cited. An exit interview was conducted and a copy of this report provided to Executive Director Mandy Taylor.