Facility Evaluation Report

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Executive Director (ED) Jolie Higgins.

LPA reviewed 9 residents files and 6 staff files. License, Administrator Certificate, and personal rights posters were observed in the facility.

LPA toured the facility inside and out with ED. The facility has four stories and basement. LPA toured the basement, first floor, second floor, third floor and forth floor including lobby, front desk, bistro area, dining room, activity room, theater, salon, kitchen, resident apartments, medication room, spa, enrichment, fitness room, restrooms, activity rooms, offices, storage rooms, and laundry area. LPA tested the delayed opening exit door in the memory care unit with maintenance director (S1). The alarm sounded when the exit door was pushed and cares came on site immediately. LPA inspected the courtyard.

Room temperature was observed at 72 degree F, hot water was observed at 118 degree F. Temperature of refrigerator was observed at 35 degree F, and the temperature of freezer was observed at -18 degree F. Food storage can hold the 2 days of perishable food and 7 days of non-perishable food for the entire building. Fire extinguishers were on service on 3/31/2025. The facility was equipped with smoke and carbon monoxide detectors. carbon monoxide detectors were tested, and were working fine. S1 provided the fire alarm system test report dated 09/16/2025. Medication rooms, medication carts, laundry room and chemical storage room were observed locked.