Facility Evaluation Report

On July 29, 2025, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. LPA met with the Director of Nursing (DON), Ann Kaye, and disclosed the purpose of the inspection.

The facility consisted of one building with two floors for Assisted Living and Independent Living units. The DON informed the LPA that the facility had 67 residents in care at the time, including 22 in Assisted Living and 45 in Independent Living.

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

LPA inspected randomly selected seven (7) resident rooms in Assisted Living. The rooms were found to be clean, well-lit, and equipped with the required furniture. LPA inspected the private bathrooms in random rooms. The bathrooms contained soap, grab bars, towels, a trash can, and non-slip flooring. The hot water temperature at the sink faucets measured between 114.7°F and 115.3°F. “No Smoking / Oxygen in Use” signs were observed posted outside the residents’ room where oxygen was administered.

LPA inspected the main kitchen and found it clean. The refrigerator, freezer, and pantry cabinets were checked, and there was a sufficient supply of fresh perishable food for two (2) days and nonperishable staples for seven (7) days. No expired food items were found. Open food items were wrapped and dated. The dining room was inspected and was found to be clean, with all furniture in good repair.

LPA inspected the fire extinguishers mounted on the hallway and kitchen walls and found them fully charged, with the last service tag dated 4/25/2025. LPA reviewed the Annual Fire Alarm service/test report, conducted on 03/05/2025 by Siemens Industry Inc.