Routine inspection·October 30, 2025

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA was greeted, granted entry by staff and explained the reason for the visit. Structure: The facility is a two story building and serves Assisted Living and Memory Care residents. The facility is licensed for 106 non-ambulatory residents, has a hospice waiver for 30, and a waiver for a secured perimeter. The census was 73 during the annual inspection and residents were observed in their rooms, the different activity rooms, dining areas, and exterior portions of the facility. Bedrooms: All resident bedrooms have the required furnishings: bed, lamp, chair, and storage space. Bathroom(s): Bathrooms are equipped with a working toilet, wash basin, and shower. Hot water measured in the range of 106.5 – 119.6 degrees F. Kitchen: The kitchen is locked and off limits to residents. Kitchen appliances are operational. Refrigerator/freezer log is available for review. Sharps are hanging on a wall near the stove. Food Service: A supply of perishable and non-perishable food items that meet regulation requirements was observed. The facility received two shipments a week from Costco, and two shipments each week from Dairy King. Client & Staff Files : Resident and staff files stored in locked storage cabinets behind the central desk. File Review: Six resident files were reviewed during the inspection and five staff files were reviewed during the visit. Medications/First-Aid Kit: Resident medications are stored in a locked medication room behind the central desk. Medication Review: Six resident medications were reviewed during the inspection. No discrepancies were noted. Medications are being administered as prescribed. Continued on LIC809C Linens & Hygiene Supplies: Additional hygiene items are being stored in a storage room #201. Common Area: There are activity areas on both floors of the facility and a total of three dining rooms. Exterior: There’s plenty of seating in the different outside areas. There's plenty shade and there is a shaded patio area with a table and chairs. There are lock storage bins in the back parking lot used to store commercial kitchen chemicals and commercial kitchen supplies. Bodies of Water: None. Smoke/Carbon Monoxide Detectors: Smoke and carbon monoxide detectors tested operational. Fire Extinguisher: Fire extinguisher was observed mounted on the walls in different areas of the facility. An emergency evacuation drill: Evacuation drill was conducted September 19, 2025. Drills are conducted quarterly. Emergency Phone Numbers, House Rules, Exit Plan & Menu: Facility postings are posted are available for review on the main postings board in the main hallway. Additional Comments: Emergency food and water was observed in a storage room across from the central desk. There’s a laundry room near the central desk and additional linens are stored in the laundry room. The facility receives deliveries of fresh linen once a week. P&I review was conducted for 4 residents; no discrepancies noted. Licensing fees are current. Contact information was reviewed and confirmed during the visit. No deficiencies will be cited as a result of todays visit. An exit interview conducted, and a copy of the report and appeal rights were provided.