Facility Evaluation Report

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Executive Director/Administrator (ED) James Craddock and explained the reason for the visit. James Craddock's Administrator's Certificate expires on November 8, 2026. Facility is licensed for 140 non-ambulatory residents with a hospice waiver for 10. The facility is composed of two buildings connected by a hallway. The main building (building B) is 3 stories and houses the memory care unit on the second floor. The secondary building (building A) is two stories. Building B has an interior outdoor courtyard with a water fountain. LPA observed the See Something, Say Something poster (PUB 475) posted in the main entry way of the facility. LPA and ED toured the facility. LPA observed the kitchen and dining room are clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. Emergency food and water are stored in a storage room next to the kitchen. LPA observed a 3 day emergency supply of food and water. LPA observed the TV/Library room on the first floor. There is a large screen TV, books and magazines and games for residents. LPA and ED toured 10 resident rooms. All 10 resident rooms had the required furnishings. All rooms inspected had clean and operational bathrooms. Hot water measured 108.8 degrees Fahrenheit to 118.0 degrees Fahrenheit in all 10 bathrooms inspected. LPA observed all the fire extinguishers throughout the facility are fully charged. The facility has 4 stairways, 2 in each building. LPA observed and emergency evacuation chair at each stairway. The last emergency drill was conducted on April 9, 2026. LPA observed medication is kept locked in a cart in the medication room. The first aid kit in the medication room has all the required elements. LPA and the Executive Director toured the second floor memory care. LPA tested the delayed egress doors in memory care unit. Both delayed egress doors tested operational. LPA observed shaded outdoor seating next to the dining room and in the interior courtyard. No obstacles or hazards observed inside or outside of the facility. During the visit LPA observed residents participating in card games in the TV/Library room.