Routine inspection·February 19, 2026

On 02/19/2026, Licensing Program Analyst (LPA) Nadia Shahbazi an c onducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Kandice Vergara Williams - Executive Director and explained the purpose of today’s visit. The facility is licensed to serve (121) elderly adults ages 60 and above, of which (121) can be non-ambulatory and (8) Bedridden. The facility has an approved hospice waiver for (20) residents. The facility is a four (4) story structure, consisting of the following: Ninety one (91) private resident bedrooms with own bathrooms. The third floor (The Evergreen Unit) is reserved for memory care residents and is equipped with a delayed egress system. There are separate dining rooms, activity rooms, wellness/ medication rooms and patios in Evergreen Memory Care Unit and Assisted Living Units. There are three laundry rooms, administrative offices, kitchen, hair salon and library, theater in the facility. There is no swimming pool or body of water on premises. Facility has a number of patio areas with adequate shading and a separate covered patio on the third floor for the memory care residents. At 11:50 am, LPA conducted a tour of the physical plant with the Administrator and observed the following: Facility is equipped with fire doors, delayed egress doors, fire sprinklers, fire extinguishers, cameras in patio and garage. There is internet, cable and telephone available for resident use. Facility conducts quarterly Fire and Disaster Drills, the last drill was conducted on 01/22/2026. LPA observed several fires extinguishers throughout the facility. All fire extinguishers were observed to be full; there is a scheduled fire extinguisher maintenance scheduled tomorrow, 02/20/2026, to be conducted by a contracted professional company. Smoke and mono-oxide detectors are maintained by the local fire department annually, therefore the detectors were not tested on today's visit. Continued on 809-C Facility’s main door is the primary entry/exit access. Screening/Reception area is located immediately upon entrance. Required postings were displayed at the reception area. In addition, the facility has eight (8) exit doors, two (2) exit doors on each floor with two (2) elevators. LPA observed evacuation chair by the stairwells. Roof access is inaccessible to residents. Exit routes are clearly labelled and posted throughout the facility. LPA observed the facility as clean, sanitary, and appropriately furnished in common areas. Kitchen: Facility has a commercial kitchen with two refrigerators, one walk in refrigerator, one walk in freezer, two stoves, one baking oven and ice cream freezer. LPA observed an adequate supply of perishable foods for two (2) days, and non-perishable food supply for seven (7) days located in the refrigerator, freezer, and pantry. Food was properly labeled and stored. Sharps and knives are stored in the kitchen; inaccessible to residents. Detergents and chemicals were locked in a storage room in the kitchen. Common Areas: There are living rooms with screened fireplaces on the first floor and the third floor. There are dining room and bistro on the first floor and the third floor. There are multiple activity rooms, libraries, television rooms, patios through out multiple floors, a hair salon on the second floor and a theater on the fourth floor. There are public restrooms in all floors. LPA visited two public bathrooms, in two separate floors and they both were observed to be clean and sanitary. Laundry: Facility has three laundry rooms, on floors two, three and four, each with two washers and two dryers. LPA observed all the machines in functional capacity. Laundry detergents and chemicals are automatically dispensed. Bedrooms: LPA toured multiple resident bedrooms on all four floors for safety, privacy, and comfort .The bedrooms were inspected and observed to maintain required furnishings and sufficient lightings and bed linens. All bedrooms were observed to be clean and clear of obstructions. LPA observed that a signal system is activated by a pull cord in each bathroom and bedroom. At 12:42pm in room# 220, LPA pulled the assistance cord; caregiver responded within 2 minutes. At 1:05pm LPA pulled that assistance cord in room# 412 and a caregiver responded in 2 minutes. Continued on 809-C Bathrooms: LPA toured multiple resident bathrooms on all four floors; all were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, non-slip mats, anti-slip floors). Hot water temperature measured between 108.7 °F. and 112.5°F; within the required range. At 1:15pm in bathroom# 311A, LPA pulled the assistance cord; caregiver responded within 3 minutes. Medications: Facility has two separate Wellness/Medication rooms and in Evergreen Memory Care Unit and Assisted Living Unit. All medications were observed to be locked in medications carts, inaccessible to residents. LPA reviewed Medication Administration Records (MARs) for eight (8) residents and compared them to the medication count and found no discrepancies. Multiple First Aid kits and the First Aid Manual were observed in the Wellness Rooms as well. Due to time constraints, LPA was unable to complete today's annual inspection. LPA will return to facility to review administrative, staff and resident records and to complete the inspection at a later date. No deficiencies sited during today's visit. Exit interview was conducted, and copy of the report was given to facility Administrator.