Facility Evaluation Report

On May 27, 2025 at 8:00am, Licensing Program Analysts (LPASs) Eboni Bentley and Jenifer Tirre made an unannounced visit to the facility for the purpose of conducting an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPAs were greeted and granted entry by Dining Services Manager, Sergio Mendoza and stating the purpose of the visit. Administrator/Executive Director (AD), Melanie Washington was notified and assisted with the visit.

LPAs reviewed the facility's resident census, staff roster, Emergency and Disaster Plan, Infection Control Plan, staff schedules. A sample of ten staff records and ten resident records were reviewed during the visit. Background clearance and association to the facility was verified for staff members on the roster.

Emergency safety drills was last conducted on March 10, 2025 and are conducted quarterly. First aid kit is maintained and contains all the necessary elements. Smoke and carbon monoxide alarms were inspections were reviewed and observed operational. The facility has several fire extinguishers that were charged throughout the facility, all last serviced on or around August 7, 2024. Liability Insurance is effective December 23, 2024 through December 23, 2025.

The facility is a two-story building arranged around a central courtyard. LPAs conducted a tour of the interior and exterior of the physical plant. Rooms reviewed were provided with furniture in good repair, clean linens, adequate storage space, and kept free of obstructions. Bathrooms were observed to be in good repair, with non-skid strips and grab bars on the inside of the shower. Hot water was measured between 125.4 and 130.2 F in three out of ten separate bathrooms throughout the physical plant.