Routine inspection·September 24, 2025

On 09/24/25 Licensing Program Analyst's (LPA's) Villegas and Brown conducted an unannounced annual required visit using the CARE Inspection Tool. LPA's met with Executive Director Suzette Johnson as the purpose of today’s visit was explained. The facility is licensed to serve 300 non-ambulatory elderly adults 60 and over of which 10 may be bedridden, there is an approved hospice waiver for 50 residents. The facility has a dementia wing w/ delayed egress. Annual fees are current, the facility has an active liability insurance with expiration date of 10/26/25. The facility is a 3-story structure located in a residential neighborhood and consists of the following: 278 bedrooms, 4 common bathrooms, multimedia rooms, commercial kitchen, activity room, large dining room, medication room, a large outside patio, laundry room, and administrative offices. There is an memory care unit is located on the 2nd floor of the facility which contains delayed egress doors that were observed to be operable, a common space, dinning/kitchen area, med room, administrative office, and laundry area. LPA’s conducted a records review of 6 staff records, 10 resident records, and 10 medication administration records, records were maintained accordingly with no discrepancies. LPAs observed medications were centrally stored and properly locked. The last fire and disaster drill was conducted on 09/15/25 by the fire safety services inc., fire extinguishers fully charged and observed throughout the facility, carbon monoxide detectors, smoke detectors and auditory signals are operational. Fire/Smoke door inspection conducted on 06/05/25 by DC Electronics, inc. Evacuation chair observed on on each floor at the stairwell. During facility tour 6 Resident bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, showers were free of mold/mildew, and there are sufficient toiletries accessible to residents. Pull cords observed in every bathroom, Water temperatures were tested in the kitchen(s), and in 6 bedrooms. LPAs conducted tour of commercial kitchen, LPAs observed an adequate supply of perishable and non-perishable food. Toxins and knifes were observed to be inaccessible to residents. Exits/ Walkways around the facility were free of debris and hazards. Exit interview conducted, appeal rights explained, and a copy of this report was provided.