Inspector’s narrative
What the inspector wrote
On 3/30/2026, Licensing Program Analyst (LPA) M. Medina conducted an announced Pre-licensing Inspection. LPA introduced met with Executive Director/Administrator, Jeffrey Toomer to conduct facility inspection.
Fire clearance was granted by the local Fire Department for a capacity of 376, of which 268 may be non-ambulatory on floors 1 and 2 and 108 bedridden on floor 1 for buildings A & B. Delayed egress approved in memory care and secured perimeter for facility.
LPA conducted a tour inside and outside of the facility. The following areas were toured and inspected:
The following areas were toured in Building A: Front Lobby, Mail Room, Fitness Center, Laundry Room, Supply Room, Kitchen, Private Dining Room, Dining Area, Library, Medication Room, Kitchen, Activity room and Hair Salon. The following rooms were toured on 1st floor: 102, 111, 117, 122, 133, 139. 2nd floor: 207, 221, 229, 236, 243 and 3rd floor: 303, 316, 330, 346.
The following areas were toured in Building B: Front Lobby, Kitchen, Dining Room, Mail Room, Medication Room, Library, Internet Cafe, Movie Room, Fitness Center and Hair Salon. The following rooms were toured on 1st floor: 106, 112 and in Memory Care: 118, 126, 134, and 137 and 2nd floor: 205, 221, 228, 243, 251 and 256.
During facility tour of individual room, LPA observed bathrooms to have operational fixtures with grab bars and slip resistant surfaces. IIn Building A, LPA observed water temperature to measure between 105 degree F and 117 degrees F throughout building. In Building B, LPA observed water temperature to measure between 105 degrees F and 119 degrees F throughout building.
The following Independent living Villas were toured: 410-D, LPA observed water temperature at 120 degrees F and 411D, LPA observed water temperature measured at 110 degrees F.
Kitchen toured, facility receives food deliveries twice weekly. Refrigerator temperature maintained at 40 degree F and Freezer temperature maintained at 0 degree F.
Fire extinguishers observed in every hallway throughout buildings and on each floor with a service date of 1/6/2026. Carbon monoxide detectors throughout buildings on each floor. Facility is equipped with fire alarm pull stations and fire sprinklers throughout building.
Outside of facility toured, no hazards observed. LPA observed pool to be surrounded by a locked gate and inaccessible to residents.
Component III conducted with Administrator and Applicant (via telephone) during pre-licensing visit.
Exit interview conducted and a copy of report provided for facility records.
Pre-Licensing is complete and this facility has no deficiencies
