Facility Evaluation Report

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Khatera Bahadory and discussed the purpose of the visit.

The facility is a two story building with seventy three resident bedrooms, three staff offices, two laundry rooms, two court yards, a medication room, dinning room, TV lounge, and kitchen. The facility appears clean, safe and sanitary. All resident bedrooms have the required components and furnishings. LPA observed resident bathrooms to have toilet paper, grab bars, paper towels and nonslip mats in the shower. LPA tested the water to be between 109.4-118.4 degrees Fahrenheit. LPA observed the laundry room on the first floor to be locked and made inaccessible when not in use. LPA observed the first floor medications cart and the memory care unit medications cart to be on the first floor and locked making them inaccessible to residents in care. LPA observed the laundry room on the second floor to be unlocked for assisted living residents to use. LPA observed the medication room to be on the second floor with medication carts locked and made inaccessible to residents in care. LPA observed the first aid kit to be in the medication room and has all the required components. LPA observed the memory unit doors to have operational delayed egress. LPA observed the kitchen to be clean and free of vermin. LPA observed a two day perishable and seven day nonperishable food supply on hand. LPA observed fire extinguishers in the kitchen and throughout the facility charged and with a service date of August 6, 2025. LPA observed the toxins and chemicals to be on the housekeeping carts and locked in the maintenance room behind the facility and made inaccessible to residents in care. LPA observed activities being conducted in the dining room during the inspection with residents.