Facility Evaluation Report

In conjunction with complaint visit today, Licensing Program Analysts (LPA) Zabel Chochian initiated the annual inspection. LPA met with the Wellness Nurse, Brenda Morales and Executive Director Scott Keawekane.

From approximately 11;45am-1:30pm, the LPA along with the Wellness Nurse, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

COMMON AREAS: The LPA observed the dining room and common areas to be clean and in good condition. There are games and/or activity supplies in the activity rooms as well as throughout the facility. There was sufficient space to accommodate both indoor and outdoor activities. The facility maintained a comfortable temperature. Required postings were observed throughout the common space. Stairwells on the third (3rd) floor have emergency evacuation chairs. There were no obstructions and/or tripping hazards throughout the facility. Delay egress exit doors in the memory care were tested and functioned properly. Several fire extinguisher checked throughout the facility were observed to be fully charged and last serviced on 12/11/2025. RECORD REVIEW: The LPA reviewed resident files from approximately 2pm-3:45pm. Ten (10) resident files were reviewed for, but not limited to, signed admission agreements, current medical assessments, TB test results, Consent for Treatment form, and current needs and services plan. The Safeguards for Property/Valuables record was missing in 10 out 10 resident files reviewed today. All other records were in order.

Due to time constraints, annual inspection will continue on a later date. No immediate health and safety issues observed during today's visit. Exit interview conducted. Copy of the report was provided.