Facility Evaluation Report

On 7/23/2026 Licensing Program Analyst (LPA) LaVette Farlow made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA was greeted and granted entry by Concierge Darlene Seno. LPA was escorted to the private dining room to work. LPA later met with Facility Executive Director, Roger Endert and Director of Health and Wellness, Jessica Padron. The facility is a Residential Care Facility for Elderly (RCFE), Licensed capacity is (120) current census (109). LPA Farlow was accompanied by Jessica to conduct a general overall inspection, 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 obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected residents bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms, and showers. The water temperature in the shower tested at 118.9 degrees F. LPA was unable to get an accurate reading from the residents sink due to the sink having a motion sensor and the water did not run for a sufficient amount of time. A Technical Advisory issued . The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for client/staff files. Medications are kept inside Med-Room inaccessible to residents. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. LPA did observe a storage self with expired can good that needed to be destroyed and removed. The Director of Culinary Services advised LPA that those items are no longer in inventory and we are in the process of destroying them. The Director had the items removed immediately. A Technical violation issued. LPA conducted a tour of the Memory Care unit, during the tour LPA observed a knife on the counter on the side of the microwave and a pair of scissors in the kitchen drawer unsecured. Jessica immediately secured both items. A Deficiency cited.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.