Facility Evaluation Report

Licensing Program Analyst (LPA) E. Conchas made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Executive Director Schamone Bard assisted with the overall inspection of the facility which included, but was not limited to the following:

Physical Plant : The facility is operating in the capacity approved by Community Care Licensing (CCL) There are no pools or other bodies of water located on the premises. There are no firearms or ammunition kept at the facility. The facility is maintained at a comfortable temperature at 77 degrees throughout the living quarters of the residents.

The outdoor and indoor passageways are kept free of obstruction. The hot water temperature was measured which measured at 107 degrees. There are grab bars for each toilet, bathtub and shower used by residents. Smoke detectors and carbon monoxide devices were observed and tested. Fire extinguishers were fully charged and their last drill was on 11/4/2025. Emergency drills were observed completed but not in a quarterly manner a technical assistance was issued. LPA observed some bathrooms not having non-skid mats. A technical assistance was issued.

Care and Supervision : The facility appears to have enough staff members to care for the residents needs 24/7.

Record Review: LPA reviewed residents files for admission agreements, updated physician reports. Medication Administration Records (MAR’s) appeared to not be administered as prescribed by their physicians. A deficiency was cited.