Routine inspection·September 18, 2025

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection utilizing the CARE tool. LPA met with Assistant Administrator and explained the purpose of the visit. Today's visit, LPA and Assistant Administrator conducted a tour of the interior and exterior of the facility to ensure the health and safety of residents in care. LPA observed facility to be at a comfortable temperature of 73*. LPA observed carbon monoxide and fire alarms to be present and operable. LPA observed bathrooms to be clean and sanitary with nonskid mat. LPA observed facility to have at least two days of perishables and seven days of nonperishable foods present. LPA observed sharps, toxins and medications to be properly locked and secured, inaccessible to residents in care. In areas toured, no immediate health safety and personal rights violations observed. LPA conducted file review of six residents records and two personnel records. LPA observed residents in the care to have updated LIC 602 with documentation of behavioral expressions. LPA observed personnel records to have completed annual training in file. File review of Emergency Disaster Plan to be recently reviewed and updated on June 27, 2025. File review of Facility Infection Control Plan to be recently reviewed and updated June 24, 2025. File review of fire drill was recently conducted on June 17, 2025. CARE tool completed with Assistant Administrator and found facility to be in substantial compliance. Exit interview conducted and a copy of the report was provided.