Facility Evaluation Report

On August 29, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection. LPA met with Executive Director (ED), and explained the purpose of the visit. Today's census is 76 residents in care, with four residents on hospice. Facility is licensed for 120 residents, hospice waiver of 15.

Today's inspection, LPA and ED conducted a tour of the interior and exterior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: facility courtyards, library, private dining room, main dining rooms, activity room, fitness center, media room, laundry room, business office and residents bedrooms and bathrooms. LPA observed fire extinguisher present throughout the facility with recent service date of August 13, 2025. LPA observed residents in care, participating in yoga session. LPA observed residents playing bingo in the activity room. LPA observed residents to be doing physical therapy in the fitness center. In areas toured, LPA observed no health, safety and personal rights violations.

LPA conducted a file review of eight resident records and eight personnel records. LPA observed resident records to have the required documents completed. LPA observed personnel records to have required initial training. When asked, Business Director informed LPA that not all care providers are provided cardiopulmonary resuscitation (CPR) training. Business Director stated all culinary staff, working 6 AM to 8 PM, are CPR certified. Additionally, the care providers and medication technicians on nocturnal (NOC) shift are CPR certified to ensure that at least one staff member who has CPR training and first aid training is on duty and on the premises at all times.