Facility Evaluation Report

On 3/24/26, Licensing Program Analyst (LPA) Kyle Wellington made an unannounced visit to the facility to conduct an annual inspection. LPA met with the Administrator (Admin), Michael Zuletta, who was informed of the purpose of the visit. Admin told LPA there are 73 residents and 87 staff members at the facility. The facility has a fire clearance to serve 104 non-ambulatory residents and an approved hospice waiver for 30 residents with 12 residents currently receiving hospice services. LPA received a resident and staff roster from the Admin. LPA did an observation of the inside and outside of the facility with the Admin and conducted record reviews for the inspection.

The facility is a one story building designated for memory care residents. The facility has a large dining room and common areas available for resident use along with outside shaded areas with seating. Indoor and outdoor passageways are free of obstructions. No bodies of water were observed on the premises. There were fire alarm systems, carbon monoxide detectors, and charged fire extinguishers throughout the facility. The fire extinguisher service tags noted the fire extinguishers were last serviced on 3/2/26. LPA reviewed the Inspection and Testing Certificate provided by JJJ Enterprises noting the facility's fire alarm and signaling systems passed their inspection conducted on 3/9/26. LPA reviewed the facility's Fire/Disaster Drill noting the facility's last fire drill was conducted on 2/17/26. LPA observed the laundry and supply rooms to be locked and inaccessible to residents, LPA toured the kitchen and observed food stored in a safe and clean manner. The facility has a two day supply of perishable foods and a seven day supply of non perishable foods. LPA observed a card rack on the kitchen wall noting residents' food allergies and dietary needs. LPA observed medications secured in medication carts, only accessible to authorized personnel such as nurses and medication technicians. LPA reviewed two staff and two resident files. The files contained all the required paperwork. LPA observed that all facility exits were clear of obstructions and had the required signage.