Facility Evaluation Report

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 9:45 a.m. Upon arrival, LPA Mosley was greeted by staff who called the Administrator to inform them of the visit. The Administrator arrived shortly after. The LPA met with Administrator Tammy Frame and explained the reason for the visit. The LPA along with Administrator 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.

INTERVIEWS : From 9:49 a.m. – 10:07 a.m. One (1) staff and two (2) resident interviews were conducted during the inspection. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interviews revealed that no concerns were noted or voiced at the time of the visit.

COMMON AREAS : At the time of the visit, furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. At 11:07 a.m., smoke detector(s) and carbon monoxide detectors were tested and operational at the time of the visit. The three (3) fire extinguishers were observed and fully charged on 5/8/2025. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 03/25/2025 and conducted quarterly. Activities were observed in the common areas. The facility has a working telephone on the premises. Auditory alarms on all doors were functional at the time of the visit. Entry/exits were free of obstruction.

GARAGE: The garage was observed locked and inaccessible to residents at the time of the visit. The facility has a sufficient supply of emergency food and water which was observed to be in good condition. LPA observed a freezer in the garage, the food was inspected for dates and food labels that had expiration dates clearly marked. Report Continued on LIC 809C...