Facility Evaluation Report

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced case management visit to complete the annual inspection from 4/7/2025. LPA was greeted by, identified herself to, and explained the purpose of the visit with Executive Director Kimberly Malaspina.

The facility is licensed for a maximum capacity of 136 non-ambulatory residents, 20 of which may be bedridden in any room. The facility has a waiver for 20 hospice residents. The facility also has approval for delayed egress for the facility's memory care. During today’s visit, the facility had a census of 73 residents. The Administrator for the facility is Kimberly Malaspina and their certificate was valid and current.

During visits on 4/7/2025 and 4/25/2025, LPA toured the facility and inspected a random sampling of resident rooms, common bathrooms, kitchen, common areas, and outside space. No bodies of water were observed on the premises. LPA observed the delayed egress to be operational. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 111.7, 115.0, 115.0, 115.4, 115.9, 116.8 and 118.4 degrees Fahrenheit across random sampling of resident rooms and common bathrooms. The facility’s internal temperature was measured at 71, 72, and 76 degrees Fahrenheit across the facility. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Kimberly Malaspina, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and labelled.