Facility Evaluation Report

At 8:30am on 01/08/2026. Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to conduct the facility annual inspection. LPA also issued final findings on a separate complaint report on this visit. LPA met with Administrator Susan Marsh who provided verbal permission for Care Staff Elena Perez (S1) to sign for both complaint and annual inspection as Administrator had appointments.

LPA toured facility with facility staff. The facility has 4 single occupancy and 1 double occupancy bedrooms and 3 bathrooms. LPA noted backyard and front yard both had chairs, tables and shade for resident activities and visitations. LPA noted two smoke detectors functioning and working properly where located at each end of the hallway. Fire extinguisher is located in the kitchen and is fully charged and serviced. Inside and outside passageways are free from obstruction. There are no bodies of water on the facility property. The facility temperature was 73 degrees F. Water temperatures were noted to be within 105-120* (f). Residents’ rooms are appropriately furnished with adequate lighting. LPA observed more than two days of perishable and more than seven days of non-perishable food. An Emergency and Disaster Plan and Personal Rights are available and located on the facility kitchen wall. LPA observed Administrator Certificate to be current. Resident and Staff files reviewed. LPA's reviewed Emergency Disaster Plan and Infection Control Plan. LPA reviewed Centrally Stored Medications Records. LPA noted that at this time there were no issues with record reviews. LPA noted that the carbon monoxide detector was not functioning at the time of annual inspection due to dead batteries and a citation was issued.. LPA noted that Administrator ordered a plug-in carbon monoxide detector for replacement during annual inspection. LPA conducted a full review of annual care tools with S1 and Administrator.

Exit interview, report read, citation issued appeal rights and report provided.