Routine inspection·October 8, 2025

On October 10, 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 Executive Director and Health Wellness Director, and explained the purpose of the visit. There are 73 residents in care in the memory care and assisted living unit, with five resident on hospice services. Facility is licensed for 108 residents with hospice waiver of 20. Today's visit, LPA and Health Wellness Director conducted a tour of the facility. Areas toured included but not limited to: five memory care bedrooms, five assisted living bedrooms, laundry room, medication chart room, salon, service room, exercise room, activity art room, theater room, lounge, dining room and the common areas. LPA observed residents room to be free of medications, sharps and toxins. LPA observed the facility to have the required posters posted in the common areas. LPA observed fire extinguisher to be serviced month of January 2025. LPA conducted a file review of ten (10) residents records and five (5) personnel records. LPA advised Health Wellness Director how best practice for files and provided a copy of LIC 311F. LPA and Health Wellness Director discussed recent fire drill conducted last week for AM, PM and NOC shift. LPA advised Health Wellness Director that fire drill log and Emergency Disaster Drill should be kept together for review. At this time, LPA is requesting a copy of LIC 500 and liability insurance. Care tool was completed and no deficiencies cited. Exit interview conducted and a copy of report was provided.