Routine inspection·April 14, 2026

Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced visit to conduct a required annual. Facility is licensed for 78 non-ambulatory residents. Facility has an approved hospice waiver for 10 residents.. Administrator Jeremy Gilmore has an administrator certificate expiring on 10/21/2027. LPAs Lyman and Mendivil along with Administrator Gilmore toured the facility at 10AM. LPAs toured the physical plant, checked food service, facility records and the first aid kit. The facility consists of three stories including a library, bistro, cinema room, game room and hair salon. Memory Care is accessible through secured door near dining room. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 105 degrees F and 118.7 degrees F in all restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Emergency pull cord response times were immediate. Common areas were clean and clear of hazards, doorways were free of obstructions. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Facility had posted appliance temperatures and all were in range. Dining room has varied menu choices for residents. Smoke detectors and fire/ sprinkler inspections are conducted by a third party on 02/03/2026. Fire extinguishers were fully charged. LPAs reviewed the emergency disaster plan and plan is thorough and complete. Facility conducts emergency drills with the last drill conducted on 03/20/2026. . LPAs observed ample emergency food and water. Outside grounds were toured. LPAs observed outside patio areas for both assisted living and memory care. There is ample outdoor shaded seating for residents. Walkways around the facility were clear of hazards. There are no security bars or weapons on the premises. LPAs observed residents participating in activities and facility offers an array of activities including outings in the community. First aid kit contained all required items including tweezers, scissors and thermometer. LPAs reviewed ten resident files and six staff files. All resident files contained required documentation including admission agreements, physician reports and resident appraisals. Staff files reviewed contained required documentation including medical assessment, criminal record clearance and proof of CPR training. LPA Mendivil observed 5 out of 6 staff did not have required annual training hours. LPAs reviewed medication administration and storage. Medications are stored in locked medication carts and facility utilizes an electronic medication record. Medications appear to be administered per physician order. Based on the observations made during today's visit, deficiencies are being cited. Exit interview conducted and a copy of this report was left at the facility.