Facility Evaluation Report

On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 70 non-ambulatory residents. Facility has an approved hospice waiver for 12 residents. The facility has 41 current residents. Executive Director (ED) Christine Greenway assisted with the inspection.

LPA along with ED toured the facility at 9:25 AM. LPA toured the physical plant, checked food service, and facility documentation. The facility is a two story building with three courtyards and surrounding parking lot. LPA inspected five resident bedrooms at random and verified they each had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 112.6 degrees F and 116.2 degrees F in five bathrooms checked. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Egress exit alarms were operational during today's visit. LPA observed residents moving around freely throughout the facility and utilizing the courtyard. LPA toured the kitchen and observed sufficient perishable and non-perishable food stocked at time of visit. Kitchen appliances were operational during today's visit. Outside grounds were toured. Courtyards were clear of hazards. There is shaded outdoor seating for residents. LPA observed the emergency food and water supply. Smoke detectors and fire systems were last serviced on 5/26/26 by Delta Fire Protection. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 3/23/2026. First aid kit contained all required items including tweezers, scissors and thermometer. LPA observed the evacuation chair installed by the stairs. Facility conducts activities in the form of exercise, art therapy, and games. LPA reviewed five resident files and six staff files.