Routine inspection·March 24, 2026

On 3/24/2026 at approximately 09:45 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. LPA was greeted by staff and stated the reason for their visit. The Administrator, Penda Hodges along with the Operational Specialist, Latanya Jules assisted with today’s visit. LPA asked for the census, Staff/Resident Roster and Liability Insurance. LPA conducted a physical plant tour at approximately 01:00 PM and the following was noted: The facility is a two-story building with an Assisted Living unit located on both floors and a Memory Care unit located on the first floor. The facility is currently occupying ninety-four (94) residents. The facility has an approved fire clearance for one hundred fifteen (115) Ambulatory/non-ambulatory and/or bedridden residents. Hospice waiver approved for twenty (20). Common areas: The common areas were observed to be neat, clean and organized. Such included are: Dining room, Activity room, Theater/Chapel, Mail room and Beauty Parlor. The rooms were observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 75°F. The hallways and passageways were observed to be free of obstruction. The stairways were observed to be equipped with evacuation chairs. LPA observed there to be two (2) elevators which were observed to be functional. The fireplace was observed to be covered and inaccessible to residents. LPA observed multiple fire extinguishers to be located throughout the facility on both floors and dated 2/03/2026. LPA observed required postings such as Long-Term Care Ombudsman, See/Say Something and facility’s license to be located throughout the common areas. Office/Work Station: The Administrative offices were observed to be located near the main entrance, near the front desk. (continued on LIC 809-C) Kitchen: The kitchen was observed to be clean and free from pests. The kitchen was observed to be a commercial kitchen with a variety of commercial-grade appliances and fixtures such as but not limited to: high-capacity gas ranges, convection ovens, fryers and stainless steal prep tables. LPA observed the kitchen appliances to be working and in proper condition. Sufficient supplies of seven (7) day nonperishable foods and two (2) day perishable foods were observed. The cleaning solutions/toxins were observed to be kept in a locked storage closet. (continued on LIC 809-C) Surrounding Grounds: The Memory Care unit is located on the first floor with thirteen (13) rooms and a capacity of eighteen (18) residents. LPA observed both dining room and living room to be in good repair and free of obstructions. LPA observed delayed egress to be in good repair and working condition. Outside of the memory care, LPA observed there to be an enclosed courtyard with an open space Gazebo. The outside area of the Assisted Living unit was observed to be equipped with a gazebo and sufficient shaded areas with outdoor furniture for residents. There is no body of water located in the facility. Laundry Room: There are four (4) laundry rooms. One (1) commercial laundry room was observed to be located on the first floor, besides the medication room. LPA observed the commercial laundry room to be kept locked. There is an additional comunity laundry room located on the first floor. There are two (2) community laundry rooms located on the second floor for residents to use. LPA observed the community laundry rooms to be accessible to residents, but no detergents or cleaning supplies were accessible. Bathrooms: LPA observed a total of four (4) public restrooms. Three (3) located on the first floor and one (1) located on the second floor. The bathrooms were checked for cleanliness and proper operation. The hot water temperature was measured within regulations. LPA observed appropriate grab rails and slip-resistant mats to be in proper condition. Bedrooms: The Residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. The bathrooms within the residents’ rooms were checked for cleanliness and proper operation. LPA observed appropriate grab rails and slip-resistant mats to be in proper condition. The hot water temperature was measured at a range of 116.4°F-120°F. Medication Room: LPA observed the medication room to be located on the first floor and to be kept locked, inaccessible to residents. The medication usage was observed to be recorded and stored properly. LPA along with the Business Office Director, Ashley Lopez conducted a review of the medication to ensure compliance. First-aid kit was observed. (continue to LIC 809-C) Smoke detectors and carbon monoxide: The facility was last inspected for maintenance and operational use of their automatic sprinkler system on 10/01/2025. The facility was last inspected for maintenance and operational use of all fire alarms on 10/01/2025. The last Fire Drill was conducted on 02/27/2026 where the smoke detectors and carbon monoxides were documented to be working properly and tested. Residents/Staff Records: LPA conducted a complete file review of nine (9) resident records. Resident records appeared to be complete. Staff records: LPA conducted a complete file review of six (6) staff records. Staff records appeared to be complete and updated. There were no immediate health and safety hazards observed during the day of inspection. Exit interview was conducted and a copy of this report was provided to the Administrator.