Facility Evaluation Report

At 9:00am on 11/06/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the facility annual inspection. Additionally, LPA issued final findings to the allegations to a separate complaint on a separate report. LPA met with Community Relations Director, Sarah Kau (CRD), LPA announced who he is and the reason for this visit. CRD made phone contact with Administrator Morgan Williams who was unavailable for annual inspection, who provided verbal authorization for CRD to sing for annual inspection report and compliant findings.

This facility is approved for a maximum capacity of one hundred thirty (130) residents. All residents licensed and approved for non-ambulatory status, of which ten (10) may be bedridden. Facility is approved for delayed egress, with an approved hospice care waiver for twenty (20) residents. This facility has a main kitchen for all residents of the facility, and two (2) dining rooms. One (1) dining room is specifically for the Assisted Living residents of the facility, and the other dining room is for the Memory Care residents of the facility. CRD and LPA conducted physical inspection facility grounds outside, in-closed courtyards and building including resident rooms, storage, kitchen, dining rooms, medication room and offices. LPA observed at least 2 days of perishable food and at least 7 days of non-perishable food items maintained in the facility and sufficient emergency water supply located in the facility kitchen. LPA noted that resident rooms all have on suit bathroom. All resident rooms had required furniture and linins per regulations. LPA observed facility Maintenance Supervisor tested water in resident memory care bedroom that exceeded regulation standards of 120*(f), citation was issued [87303(e)(2)]. LPA observed chemicals stored in unlocked cabinet in memory care unit, citation issued [87309(a)]. LPA observed door to facility kitchen not operating properly and not closing as designed, and courtyard fountain in disrepair with loose rocks in the walkway surround fountain, citation issued [87303(a)]. No other citations or violations noted during the physical inspection of the facility. CONTINUED on LIC9099-C