Routine inspection·May 27, 2026

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Required Annual Inspection. LPA identified himself and discussed the purpose of the visit with Chief Operating Officer (COO) Lynn Drummond. The facility is Licensed to serve 21 residents ages 60 and above; of whom all may be non-ambulatory, 12 bedridden residents, and 15 whom can be receiving Hospice services. LPA, accompanied by Med-Tech Gerald Madla toured the interior and exterior of the facility, and inspected every resident's room. The facility was clean and sanitary. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present. Hot water temperature was measured in the facility at an average of 113 degrees F. The ambient temperature inside the facility was measured at an average of 73 degrees F. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, as required, and stored in locked areas. Their are no bodies of water on the premises. Per COO, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. [CONTINUED ON LIC 809-C] LPA reviewed multiple staff and resident records/files. LPA file review did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas. During resident interviews it was revealed that a deficiency took place in regards to basic services. Based on interviews and LPA observation deficiency was observed and cited on the attached LIC 809D. An exit interview was conducted with Chief Operating Officer Lynn Drummond to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.