Facility Evaluation Report

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Executive Director Bryan Hadley and explained the reason for the visit. Bryan Hadley's Administrator's certificate expires on February 3, 2027. Facility is a two story building with 114 resident rooms which includes a memory care unit. Facility is approved for delayed egress exits in the memory care unit. Facility is licensed for 125 non-ambulatory residents with a hospice waiver for 25. LPA and the Executive Director (ED) toured the facility. LPA observed the See Something, Say Something poster (PUB 475) posted in the main entrance. LPA and the ED toured the kitchen and dining room. LPA observed the kitchen is clean and organized. There is a two day supply of perishable food and a seven day supply of non-perishable food on-hand in the kitchen. The refrigerators and freezers were at the required temperatures. LPA observed temperature logs posted on the refrigerator. LPA observed a 3 day emergency food supply stored in a supply closet. LPA observed a 3 day emergency water supply stored outside next to the courtyard. There is a courtyard outside the dining room in assisted living. The courtyard has shaded seating to sit outside and a fountain. LPA and ED toured 10 resident rooms on the first and second floors. All resident rooms had the required furnishings and bed linens. All resident bathrooms were clean and operational. The hot water in the resident rooms inspected measured 111.0 degrees Fahrenheit to 116.9 degrees Fahrenheit. There is a library next to the dining room with games and puzzles and a TV room for residents. During the visit residents were participating in a music activity in the great room next to the library. LPA observed all the fire extinguishers throughout the facility were fully charged. The facility has 4 stairwells. LPA observed an emergency evacuation chair at the top of each stairwell. LPA observed the facility has a desktop computer with internet access for dedicated resident use in the activity room.