Facility Evaluation Report

On July 03, 2025, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a unannounced Case Management – Health Check inspection visit. LPA met with the Administrators (ADM1) Zach Pilkerton and (ADM2) Fe Arnaiz and disclosed the purpose of the inspection. There were 33 residents in care and 10 staff members present at the time of the inspection.

LPA initiated a walk-through of the facility, accompanied by the ADM1.

LPA inspected a centrally stored medication cart in the medication room. Med tech was preparing for the med pass at that time. Centrally Stored Medication Records were reviewed for random residents. Narcotics medication count was performed for two (2) residents (R1 and R2), and the count was found to be complete.

LPA inspected common areas and observed two (2) residents sitting in the dining room with their visiting families. LPA observed residents watching TV in the TV room. LPA toured the outside areas and observed two (2) residents sitting on the front deck.

LPA observed that the facility didn’t have any auditory devices to monitor exits on the exterior doors of the facility building. LPA observed a delayed egress rolling iron gate controlling the driveway entrance / exit, next to the perimeter fence. This gate was the only way cars and people can come in and out of the facility. An auditory alarm was observed in the front office / lobby area when this gate was opened. The exterior perimeter of the facility was observed to be fenced.

No deficiencies were cited during today's visit.

An exit interview was conducted with the Administrator. A copy of this report was provided to the Administrator, Zach Pilkerton, whose signature on this form confirms receipt of the report.