Facility Evaluation Report

On 3/28/2025, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA met with Administrator, Kelley Lara who was informed of the purpose of the visit. The facility is licensed to serve for 98 elderly non-ambulatory elderly residents, of which 10 may be bedridden. The facility also has an approved hospice waiver for 26 residents and LPA was informed eight (8) residents are currently receiving hospice services at the facility.

LPA toured the facility and observed the facility is made up of a two-story building currently designated for assisted living and memory care. The facility has large dining rooms, a cinema, fitness room, library, piano bar, game room, along with other activity rooms available for resident leisure. LPA toured the kitchen and observed food was stored in a safe and healthful manner. The facility met Departmental requirements for a two-day supply of perishable foods and seven-day supply of non-perishable food items. LPA observed a white board on the kitchen wall noting residents' dietary needs. LPA observed fire alarm systems, carbon monoxide detectors, and charged fire extinguishers throughout the facility. LPA reviewed the Annual Fire Alarm Report dated 4/10/2024 provided by HCI Systems Inc. noting the fire alarms and signaling systems passed their inspection. LPA was informed the facility's last fire drill was conducted on 3/22/2025. Medications are secured in medication carts stored in the locked medication room. Cleaning solutions and disinfectants are secured in the locked housekeeping room. The courtyard provides outside shaded seating for residents in care. Indoor and outdoor passageways were free of obstruction. No bodies of water were observed on the premises. The facility is pending a capacity change as it is expanding and undergoing new construction, which the Department is aware of. Administrator Lara will provide clarification regarding the fire inspection request by close of business on 4/1/2025.

During today's visit, LPA did not observed any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Kelley.