Routine inspection·February 24, 2026

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit and met with Executive Director Michael Fountain (ED) . LPA toured Compass Rose (Memory Care unit) with ED to include 4 apartments (RM #129, #126, #123, #120), bathrooms, activity room, kitchen, dining room, and patio area. All fire exit routes were free and clear of obstruction. LPA checked 2 common restrooms in memory care unit. One delayed egress exit door of memory care unit was observed in working condition and the other one was under repair. LPA observed a caregiver sit outside if the exit door of the memory care unit to monitor. Room temperature maintained between 76 degrees F. Kitchen refrigerator temperature maintained at 40 degrees F. Freezer temperature maintained at 0 degrees F. Hot water temperature measured at 118 degrees F. Chemicals, disinfectants, and medications observed locked in Compass Rose. During visit, resident's observed participating in various activities. 2 resident files in Compass Rose was reviewed. 2 out of 2 resident files were complete and no issues noted. LPA inspected 2 resident's centrally stored medication and records with staff. 2 out of 2 resident medications were complete and no issues noted. LPA entered in the kitchen with the ED. The facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Items inside the refrigerator and freezer observed covered and labeled. Continue on LIC809-C. LPA toured Assisted Living with ED to include 4 resident apartments (RM #225, #218, #206, and #243) and common restrooms. Hot water temperature was measured at 118 degree F. LPA checked 2 residents file in Assisted Living was reviewed. 2 out of 2 resident's files were complete. LPA inspected 2 resident's centrally stored medication and records with staff. 2 out of 2 resident medications were complete and no issues noted. 4 staff files were reviewed and observed complete. 4 out of 4 staff members are fingerprint cleared. 4 out of 4 staff have over 20 hours of annual training. Fire extinguishers observed throughout the facility, last service date was 06/26/2025. Facility has carbon monoxide and smoke detectors present. Carbon monoxide detector was tested and was observed functional. Facility has an emergency disaster plan and emergency non-perishable foods. LPA observed the facility has a box that contains emergency supplies to include (but not limited to) flash lights, batteries, radio, reflector vests, and band aids. The last time of the facility emergency drill was done on 1/30/2026. Elevator observed in working condition. LPA observed the facility has a first aid kit. 3 stairwells were observed with an evacuation chairs. LPA toured 2 court yards and side yard with ED. The court yard of memory care unit with 2 delayed opening doors and were observed in operational condition. No citation were cited today. This report was reviewed with Executive Director, and a copy of the report was provided.