Facility Evaluation Report

On 5/12/2026, Licensing Program Analyst (LPA) Ahliah Sharp conducted an unannounced required annual visit. LPA met with Executive Director Robyn Icamen who was informed of the purpose of the visit. The facility’s current census is 49, with approval for fifty-eight (58) ambulatory, fifteen (15) non-ambulatory, one (1) bedridden resident; and a hospice waiver approved for eight (8) residents. LPA conducted a tour of the interior and exterior of the facility, reviewed facility documents and conducted five interviews; two (2) staff and three (3)residents. LPA observed the following:

LPA observed the physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good working conditions. The outdoor area was observed to be free of any hazards. LPA observed a courtyard with outdoor furniture and shaded area for residents. Facility kitchen had the ability to prepare food in a clean environment and possessed equipment in good working conditions. The sharp and dangerous objects were observed to be inaccessible to residents in the kitchen. Facility kitchen receives one shipment of food every week, ordered on Monday and arrives on Tuesday.

LPA observed the facility sketch, exit routes, personal rights, complaint information and emergency phone numbers posted around the facility. The smoke detectors and carbon monoxide detectors were operational. LPA observed the facility exceeded the required two (2) day supply of perishable and seven (7) day supply of non-perishable foods.

LPA conducted medication review with staff, and observed the medical sharps stored in locked boxes inaccessible to residents in care.