Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Required 1 Year visit and met with Executive Director (ED)/Administrator, Patricia Gustin. Required postings observed. There are eight residents receiving hospice care services within the approved hospice waiver.

Facility has an approved dementia care plan. LPA obtained staff schedules for the Assisted Living and Memory Care Units for the month of January 2026 with a census of 98 residents in care indicates that the facility had an average of two caregivers on duty for residents in care and one medication technician (med-tech). Currently, there are currently 76 residents in Assisted Living area and 22 residents in Memory Care Unit. LPA/ED observed three caregivers present in memory care, one resident care coordinator and one med-tech. There are two caregivers present in assisted living area and one med-tech, there is one caregiver present who alternates between assisted living and memory care unit to assist with showers and incontinence care. LPA/ED toured the facility which included an inspection of assisted living and memory care, all common areas, hallways, and bathrooms observed had sufficient lighting. Residents rooms are furnished per regulation. Facility's Memory Care is allocated to one floor. The facility was a comfortable temperature. Passageways were free of obstructions. Cleaning products are in locked closets or on supervised and/or locked carts. Facility has a sufficient supply of cleaners, hygiene items and paper products. Multiple first aid kits were observed. A call button is located in each bathroom, LPA tested the call system in resident's rooms and staff response time was under three minutes. Continued on LIC 809-C..