Facility Evaluation Report

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced Annual Required inspection of the facility. LPA Tea was greeted by staff, granted entry, and explained the purpose of the visit. Community Care Administrator (CCA) Claudia Lusca and Chief Operations Officer (COO) Kerri Clark arrived shortly and assisted with the inspection. The facility is licensed to serve 264 non-ambulatory residents and has an approved hospice waiver for 15 residents. At the time of the inspection, there were 163 residents in care, including five residents receiving hospice services.

LPA reviewed sixteen resident files and seven staff files. All files contained the required documentation. The Administrator’s Certificate was current and is valid through January 22, 2028.

LPA, accompanied by facility management, conducted a tour of the physical plant. The RCFE consists of two three-story residential buildings serving assisted living and independent living residents, and one secured single-story memory care building. The facility’s fire alarm system is monitored and maintained by Tri-Signal Integration, Inc., with the most recent inspection completed on June 9, 2026. Fire extinguishers throughout the facility were fully charged. The most recent disaster drill was conducted on July 14, 2026. LPA also observed evacuation chairs located in each stairwell for emergency use.

Resident bedrooms were clean and appropriately furnished with beds, linens, adequate closet and drawer space, and other required furnishings. Bathrooms were clean and in good repair. Toilets, sinks, and showers were operational, grab bars were securely installed, and showers were free of mold and mildew. Hot water temperatures measured between 105.6°F and 115.9°F, which are within the required range.

(Annual Inspection continued on LIC809-C)