Routine inspection·October 7, 2025

On 10/07/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with the executive director Cleitus Jones and explained the purpose of today's visit. There are currently 127 residents in the facility during this inspection. This is a multi-level facility, age range 60 years old and over. 140 residents may be non-mbulatory residents shall not be housed above the 2nd story. Dementia units are on the 1st and 2nd story. Units 316-326 are on the 2nd story. Hospice waiver approved for 35 residents. There are currently 9 residents under hospice care today. This facility has three secured memory care areas. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked and secured in the kitchen. Perishable and non-perishable food supplies are observed as in place. Kitchen grade fire extinguisher is observed as in place and with an inspection date of 07/26/2025. First aid kits are observed as complete with required items as observed. Medications are observed to be locked in medication rooms in memory care areas and in assisted living. Medication carts are locked and used to disperse medication to residents through out the community. LPA reviewed resident medications at random and observed them as current and stored correctly including medications in refrigeration units. LPA observed that there are multiple fire extinguishers in place on each floor with an inspection date of 07/26/2025. Smoke detectors, carbon monoxide detectors, and full fire sprinkler system is observed in place through out the facility. Central heating and air conditioning is in place. Continued on next page... Page 2 Laundry areas are also observed as fully operational clean and organized. Detergents are dispersed through push button automation systems. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Evacuation chairs are in place in emergency exit stairwells as well. Last emergency/disaster drill was conducted in 09/26/2025. Water temperature was measured at 105F in resident rooms 318B, 320B, and 240B. Room 216 was tested at 110F. Cleaning supplies are observed to be inaccessible to residents in care. Resident rooms are observed at random. LPA observed 5 resident rooms, and all are free of odors and contained all the required furniture per regulatory recommendations. Resident linen supplies are observed as in place stored in various closets and in laundry rooms through out the facility. LPA reviewed five staff files and six resident files during today's inspection and all files are observed as current. Staff are actively conducting training via Relias and it is observed as current. Administrator certificate is current expiring 04/04/2026. No citations issued. Report is reviewed with Cleitus Jones and a copy is provided on this day.