Facility Evaluation Report

On 7/25/2025 at approximately 9:30AM, Licensing Program Analyst (LPA) Ali Deniz conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. LPA was greeted by Administrator, Tedra Godfrey. The facility is a two-story building licensed for 169 non-ambulatory and 30 bedridden residents, along with a hospice waiver capacity of 20. The facility currently provides care for 148 residents, 7 of which are receiving hospice services and a dedicated memory care unit. Annual fees are current. Required postings were observed.

LPA continued with a tour of the facility with Administrator, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers found throughout the facility were found to be last charged on 06/02/2025 at the time of visit. Both smoke detectors and carbon monoxide detectors throughout the facility were interconnected and inspected by an outside agency with current certification dated 10/25/2024. Elevators were found to have current inspection certification with the date of 05/22/2025. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with food delivered twice per week. Food stored in the kitchen was properly stored as per regulations on this day at the time of the visit. Facility closely monitors resident diets with appropriate dietary restrictions posted on kitchen walls. Toxins are stored in designated facility storage closets located throughout the facility.

There was a supply of hygiene products and paper products available for residents. All residents’ apartments have lighting & appropriate furnishings. Water was measured at faucets in several residents’ private bedrooms and measured between 113.1- and 115.3-degrees F which is within regulation between 105- and 120-degrees F at faucets accessible to residents.