Facility Evaluation Report

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by front desk staff and explained the reason for the visit. Executive Director (ED) John Goodwin and Business Operations Manager (BOM) Danielle Chairez arrived shortly to assist with the visit. Facility is licensed for 148 non-ambulatory residents, of which 22 may be bed-ridden, but limited to the first and second floor, and a hospice waiver for 22 residents. Currently there are 113 residents and 7 are on hospice during today's visit.

LPA Tea reviewed twelve resident files and six staff files. Resident files and staff files contained all the required documentation. ED Goodwin’s administrator certificate expires on July 24, 2025. ED Goodwin completed and submitted all course work to renew his certificate and is pending approval. The last disaster drill was conducted on June 6, 2025.

LPA Tea along with ED Goodwin toured the facility at 2:10 PM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a three-story building, with a memory care wing, called “Clare Bridge” on the first floor. In the middle of the building is a courtyard with shaded patio seating and a fenced in water fountain with koi fishes swimming. Memory Care unit has a garden sitting area of its own in the back that is secured. LPA tested delayed egress around the memory care garden to be operational. The fire alarm system of the facility is monitored and maintained by a third-party company. Fire extinguishers are fully charged throughout the facility. LPA observed evac chairs in every stairwell in the facility for emergencies. Resident bedrooms 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 118.4 to 110.6 Fahrenheit degrees. LPA pulled emergency pendants in resident’s bathrooms. The first test, the

Annual inspection report continued on LIC809C