Facility Evaluation Report

Licensing Program Analysts (LPA) Alviso conducted a Required- 1 Year visit, on 4/1/26 at approximately 9:45am, and met with James Homer, Administrator.

Fire clearance is approved for one hundred fourteen (114) non-ambulatory, of which six (6) may be bedridden. Facility's delayed egress and secured perimeter is approved by the local fire department.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for eighteen (18) residents. Facility has an infection control plan as required. The facility has a required emergency and disaster plan.

LPA reviewed ten (10) resident files, including medication records. All medications were stored appropriately, and locked up making them inaccessible to residents, and all others that do not handle/assist with medications.

LPA toured the facility with the Administrator. All exits were free and clear of any obstructions; All walkways and paths were free and clear of obstructions. Hot water was measured in AL at 115.3 degrees Fahrenheit on the 2nd floor and 114.2 degrees Fahrenheit on the 1st floor, all readings were within regulation;

Hot water was measured in memory care unit at 118.3 degrees Fahrenheit, which is within regulation. Fire extinguishers were serviced and tagged as required. All laundry rooms were clean and orderly, in AL and memory care. Facility had a sufficient supply of food, perishable and non-perishable. Emergency supplies, and emergency disaster supplies were sufficient during today's inspection.