Facility Evaluation Report

On May 13, 2025, at 09:00 AM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. LPA met with the Executive Director (ED) Andrew Pence. The ED informed the LPA that the facility currently has 19 residents in care.

At 9:35 AM, the LPA initiated a walk-through of the facility along with the ED.

LPA inspected six (6) random resident rooms on the third floor, and found them clean, well-lit, and equipped with the required furniture. Emergency pull cords were observed to be functioning in the resident rooms with an average response time of 5 minutes. LPA inspected the private bathrooms in these 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 116.5°F and 119.8°F.

LPA inspected the dining room and found it clean, with all the furniture in good repair. Residents were observed eating snacks in the dining room. Cleaning supplies, chemicals, and sharp objects were observed inaccessible to the residents.

LPA inspected activity area and other commons areas and observed some residents participating in the activity and some watching TV. All common areas were free from obstructions and hallways were well-lit.

LPA toured the patio area and found passageways in good condition, free of obstructions, and without any blocking or tripping hazards. These areas had patio tables, chairs, and umbrellas for residents’ use. Delayed egress was observed on emergency exits and patio doors were locked. No accessible bodies of water or hazards were observed.