Facility Evaluation Report

April 8, 2025, 1:00 PM Licensing Program Analysts (LPA’s) Sarah Benson and Kayla Adkison arrived at the facility to conduct a pre-licensing inspection. LPA ‘s met with Executive Director, Patricia Clark and explained the purpose of the visit.

Key topics of the Comp III were discussed and the full presentation was waived.

The fire marshal has approved the fire safety inspection request. The facility is licensed for 56 non-ambulatory residents of which all may be bedridden. This facility has been previously licensed and is currently changing management companies. LPA confirmed there are currently 49 residents at the facility and 14 residents are receiving hospice services. Facility will request a new hospice wavier.

The facility has a memory care unit that has (30) bedrooms with (56) beds and (32) bathrooms.

The inside of the facility was observed to be in good condition and repair. LPA’s observed dining area with sufficient tables and chairs for residents. LPA ‘s observed common areas are clean and in good reapir.

The hot water meets the requirement for licensing within a range of 105 - 120 degrees F.

Food storage meets Title 22 regulation requirements. Plates, utensils, pots, and pans were in place during the inspection.

Bedrooms were observed to have furniture as required by Title 22 Regulations. All beds were made up with linens and bedspreads. Each bedroom has ample storage. Bathrooms were observed to be in good repair.

The facility has a locked medication cart which is located in the locked medication room.

Storage and lighting are adequate in the facility. Cleaning supplies and toxins are locked in janitorial rooms.