Facility Evaluation Report

On July 21, 2025, Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced annual inspection of the facility. Upon arrival, LPA Haddadin was greeted by the Executive Director (ED), Mike Marion, who granted entry and was advised of the purpose of the visit. Together, they toured the interior and exterior of the three-story building.

The facility is licensed for thirty (30) ambulatory residents and one hundred fifty-five (155) non-ambulatory residents, which includes fifteen (15) bedridden residents. The facility has an approved hospice waiver for thirty (30) residents. The total capacity is 185 residents, and the census at the time of inspection was 166. During the visit, residents were observed in the dining room enjoying breakfast, while others participated in scheduled physical activities or rested in their rooms. Eight resident rooms were chosen randomly for inspection and were found to be furnished with a bed, a chair, and clean linens. The rooms also provided adequate storage space and were free of tripping hazards.

Exterior portions of the facility, including the courtyards, were well-maintained. Furnishings were in good repair, pathways were clear of hazards, and the grounds appeared safe and inviting with a shaded seating area. Eleven fire extinguishers were checked and observed to be fully charged, with the indicators in the green zone. The hot water temperature in the randomly selected rooms was measured between 113.8 ∘ F and 115.5 ∘ F, meeting regulatory requirements.

The facility maintains sufficient food supplies, including at least a two-day supply of perishable items and a seven-day supply of nonperishables. The kitchen was observed to be in good repair, and all major appliances were operational. Cleaning supplies were stored securely and were inaccessible to residents. All medications are kept locked in the medication room on the third floor, inaccessible to residents in care.

A review of residents' files showed no discrepancies. Staff files were complete, each containing the required documentation.