Facility Evaluation Report

At 8:30am on 07/09/2026, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the facility annual inspection. LPA met with facility Administrator, Tammy Westwood, announced who he is and the reason for the visit being the facility annual inspection.

Administrator and LPA conducted physical walk through of the entire facility. This facility is located in an in-closed compound with two exterior car gates and one exterior pedestrian gate. There are 5 resident buildings and a day program building with a large kitchen that serves the entire campus. Building 11 and building 5 also have small kitchens. LPA observed at least 2 days of perishable foods and 7 days of non-perishable foods in the main kitchen to service 40 residents and staff. LPA conducted a physical inspection of all buildings and sample rooms in each building. LPA noted that rooms are properly equipped with furniture and linins. LPA noted that all buildings had two or more fire extinguishers that are all primed in the green. All buildings have two or more carbon monoxide detectors that were tested and functioning properly. LPA noted that on 05/28/2026, Nargan Fire & Safety Co. Inc. conducted a fire safety inspection on the internal fire detection system for all building on campus with a passing rating. LPA noted all buildings have a compete first aide kit. LPA noted that there is a medication room that services the entire campus, and there is a medication cart in building 11 and all other buildings have locked and secured medication cabinets. LPA noted that there are several seating areas outside that have seating and shade via pergola or umbrella for resident activities and visitation. LPA noted that the facility was clean and in good repair and all exits were free and clear of obstacles and debris. LPA conducted a review of facility Infection Control Plan, Emergency Disaster Plan, Liability insurance, Centrally Stored Medication Records, Plan of Operations, Staff and Resident files and found no issues. Administrator and LPA conducted a full review of annual care tools and found no issues. At this time there are no violations or citations as a result of the facility annual inspection. Exit interview, report read, and report provided.