Facility Evaluation Report

Licensing Program Analysts (LPAs) Quoc Huynh and Kelly Dulek arrived unannounced at 09:40AM for a required one year visit. The LPAs initially met with Health Services Director Heather Hampel and explained the reason for the visit. Administrator joined shortly thereafter. Entrance interview conducted.

Beginning at 11:09AM, the LPAs, along with Health Services Director 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. The following was observed:

COMMON AREAS: The facility is a two-story building. On the first floor, there are the kitchen facilities, dining room, Bistro, laundry rooms, Wellness Center, fitness center, office spaces, and common restrooms. On the second floor, there is a beauty salon, spa, Wellness Center, second floor dining, a private dining room, several activity spaces, office spaces and common restrooms. The LPAs observed common areas to be clean and in good condition. There were no obstructions and/or tripping hazards throughout the facility. There were cameras in the common areas, outdoor courtyard, and exterior perimeter. Required postings were found in the hallway on the first floor. There are fire extinguishers throughout the facility, which were serviced 07/21/2025. Fire alarm system is tested annually with the last inspection on 06/16/2025. 5-year inspection was conducted on 08/11/2025. Both inspections were conducted by Nelson Fire Protection; all systems passed.

RESIDENT ROOMS/RESTROOMS: The LPAs observed ten (10) randomly selected rooms on the first and second floor and no immediate health or safety hazards was observed. Restrooms were clean, with properly installed grab-bars in resident bathrooms and slip-resistant surfaces. Appropriate furniture was also observed Report Continued on LIC 809-C