Facility Evaluation Report

Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Required - 1 Year visit, on 10/21/25 at approximately 8:15am, and was greeted by staff, Tracy Nava, Health & Wellness Director (HWD) who contacted Administrator Stacy Ford that arrived during inspection. Facility has a hospice care waiver approved for six (6) residents. Fire clearance approval is for one hundred and twelve (112) non-ambulatory residents. The facility consists of two floors and provides assisted living services to residents as needed. During today’s visit there were 95 residents with one (1) under hospice care.

LPA and HWD toured the facility finding; all exits were free and clear of any obstructions. All five (5) stairwells had the required evacuation chairs. Fire Extinguishers were found to be last charged on 6/19/2025 at the time of the visit. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers are inspected, and inspection records are current. Every resident apartment has an individual smoke detector in addition to hard wired, which smoke and carbon monoxide detectors were found to be operational on today’s visit. Hot water temperature measured between 114 degrees F and 120 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 6 resident’s bathroom faucets while touring facility on 10/21/2025 at 9:00 AM. Bathrooms were equipped with necessary grab bars, and slip-resistant mats, strips, or flooring in all bathtub and shower floors as required by Title 22 regulations. All bedrooms have lighting & appropriate furnishings per Title 22 regulations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerators/freezers/storage rooms, was properly stored as per regulations on this day at the time of the visit. The facility had sufficient supplies of cleaners/disinfectants, paper products, emergency 72-hour shelter in place supplies, emergency water supplies, and sufficient supply of personal protective equipment (PPE).