Routine inspection·June 25, 2025

On 06/25/2025 at 12:00 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with General Manager, Linda Fisher and explained the purpose of the visit. The facility’s fire clearance was approved for capacity ninety (90) non-ambulatory of which five (5) may be bedridden. Hospice waiver approved for thirteen (13) residents. Administrator certificate #7017208740 expires 09/27/2026. LPA toured the facility with Care Director, Yelba Havelhorst, including but not limited to two (2) residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 74 and 76 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 108.4, and 114.5 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, sharps and toxic are locked and inaccessible to residents in care. LPA reviewed nine (9) residents records. LPA reviewed ten (10) staff records and 10 of 10 have current first aid training and associated to the facility. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 07/02/2025: LIC 308 Designation of Administrative Responsibility - Reviewed LIC 309 Administrative Organization - Reviewed LIC 500 Personnel Report - Obtained LIC 610E Emergency Disaster Plan - Reviewed Liability Insurance - Reviewed Current Administrator’s Certificate - Reviewed No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.