Facility Evaluation Report

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry by the receptionist at 8am. LPA met with Executive Director (ED) Melanie Washington and explained the purpose of the visit.

The facility is a two story building with a capacity of 210 non-ambulatory residents with an approved hospice waiver for 15 residents. LPA obtained staff and resident rosters. Currently there are 103 residents in care with nine residents on hospice.

During today's visit, LPA toured the facility and inspected the physical plant. There are two elevators and three stairwells with evacuation chairs. Fire extinguishers were charged and inspected on September 15, 2025. Carbon monoxide detectors were tested and operational. LPA requested copies of current liability and vendor testing of smoke alarms/sprinklers. The Fire system was inspected on April 14, 2025 and passed. The facility is awaiting approval for 2026 fire inspection. The facility's last fire drill was conducted on May 25, 2026. The facility temperature was seventy-five degrees. The liability insurance is current through 12/23/2026.

LPA tested the hot water temperature in five of five resident apartments. The temperatures measured between 107.1 to 113.6 degrees Fahrenheit. Resident apartments were clean, and had the required linens and furnishings. LPA did not observe medications in resident apartments. Resident bathrooms had grab bars and non-skid flooring. LPA observed the facility common areas were clean with no odors detected. LPA observed residents in the activity room engaged in activities and a resident outing to Trader Joe's. Residents came to the dining room for breakfast and lunch.