Facility Evaluation Report

Licensing Program Analysts (LPAs) Emily Peraldi and Anegla Barutyan arrived at the facility unannounced to conduct a required annual visit. At 10:30 a.m., the LPAs met with Executive Director (ED) Ken Mahler and explained the reason for the visit.

RECORD REVIEW: Between 11:05 a.m. and 2:00 p.m., the LPAs conducted a file review for ten (10) residents and eight (8) staff. Resident records were reviewed for, but not limited to: care plans, medical assessments, admissions agreement, consent forms. Resident records were in order. Personnel records were reviewed for, but not limited to: health assessments, criminal record clearances, first aid/CPR training, and training documentation showing required training completed. Personnel files were in order. Disaster drill was last conducted on 12/29/2025. Administrator certificate is current and valid until 10/18/2027. The LPAs obtained a copy of the liability insurance, resident roster and staff roster.

At 1:28 p.m., LPA Barutyan along with the ED conducted a physical plant tour to ensure there are no health and safety hazards. During the physical plant tour, the LPA conducted interviews with five (5) residents and no concerns were noted. The facility consists of one (1) memory care unit (MC), and an assisted living unit (AL). The memory care unit is secured with delayed egress doors which lead to secured outdoor patios. The second floor has no resident apartments but was observed to have a gymnasium for resident use, facility storage, and office space. KITCHEN: At 1:28 p.m., the LPA observed the kitchen and dining area. Knives are stored in the kitchen which remains inaccessible to residents. Kitchen appliances are in operable condition. The facility has a sufficient supply of two-day perishable and seven-day nonperishable food. The menu was posted throughout the dining area. Snacks and beverages are available for residents. Continued on LIC 809-C.