Routine inspection·August 6, 2025

On 08/06/2025 at 2:00 PM, Licensing Program Analysts (LPAs) L. Alexander and K. Nguyen arrived unannounced to conduct a 1-Year Annual Required inspection. LPAs met with the Director of Residents Services (DRS), Sheila Roberts, and explained the purpose of the visit. Executive Director (ED), Tracey Ingleman, arrived approximately 30 minutes late. The facility’s fire clearance was approved for capacity of 175 residents all may be non-ambulatory. Hospice waiver for fourteen (14) residents. Bedridden fire clearance for six (6) on first floor only. Administrator Certificate # 6029374740 (renew on: 6/9/2025). LPA toured the facility with Tracey Ingleman ED and Sheila Roberts including but not limited to five (5) residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms is adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70- and 74-degrees F. The hot water temperature in a sample resident’s bathroom was measured at an average of 105 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharp and toxic chemicals are locked and inaccessible to residents in care. Fire Drill last conducted on June 11, 2025, and June 18, 2025, Maintenance on 1 bus( Registration from 6/30/2025 to 6/30/2026) and 1 wheelchair van updated(Registration 5/31/2025 to 5/31/2026). Emergency Disaster Plan last updated on 6/13/2025. Liability Insurance effective date: 7/1/2024 to 7/1 2026. The fire extinguisher last inspected 3/13/2025. LIC809-C Continued... LPA reviewed ten (10) residents records. LPA reviewed nine (9) staff records and 9 of 9 have current first aid training and are associated with the facility. Updated copies of the following documents were requested for facility file and are reviewed on 8/6/2025: LIC 308 Designation of Administrative Responsibility- Reviewed LIC 309 Administrative Organization- Reviewed LIC 500 Personnel Report- Reviewed LIC 610E Emergency Disaster Plan (with last page dated and signed)- Reviewed Copy of Liability Insurance- Reviewed No deficiencies cited during the visit. Exit interview conducted and a copy of this report provided.