Routine inspection·January 14, 2026

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Required 1 Year visit and met with Executive Director (ED), Jeff Brenner. Facility has an approved dementia care plan. There are currently 42 residents in Assisted Living area and 29 residents in Memory Care Unit for a total of 71 residents in care. There are eight residents receiving hospice care services within the approved hospice waiver. Required postings were observed. Annual fees are current. LPA/ED toured the facility which included an inspection of assisted living and memory care, all common areas, hallways, and bathrooms observed had sufficient lighting. During the walk through of the two story building including assisted living and memory care, LPA/ED noticed that garbage cans located in resident's bathrooms do not have lids, LPA had a conversation with ED regarding the importance of providing garbage cans with well-fit covers (technical advisory issued). There is a home health room located in the assisted living area. Residents rooms are furnished per regulation. LPA/ED observed the memory care unit is on a delayed egress system, which it was approved in their fire clearance. The memory care area has outdoor entrance that has a door bell that it is accessible to families who gets access to the building through them. There are evacuation chairs located at each stair. The elevators were last inspected on 3/28/25. The facility was a comfortable temperature. Passageways were free of obstructions. Cleaning products are in locked closets or on supervised and/or locked carts. Facility has a sufficient supply of cleaners, hygiene items and paper products. Multiple first aid kits were observed. A call button is located in each bathroom, LPA tested the call system in resident's rooms and staff response time was under two minutes. Continued on LIC 809-C... Continued from LIC809... LPA/ED toured the kitchen area located adjacent to the building located in the independent living building. A tour and inspection of the kitchens and dining areas were found to be clean and sanitary. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. Refrigerators and freezers were at required temperatures. Prepared and left over foods were covered and labeled. Menu includes a wide variety of foods from all of the food groups. A board in the kitchen has written instructions for residents with food allergies and restricted diets. All medications and toxins/cleaners were all locked and inaccessible to residents in care. The facility has emergency supplies, including food and water to meet requirements of the 72-hour shelter in place. During the tour, residents were observed participating in group activities in common areas. There are activities written on a board specified for both assisted living and memory care engagement. The last fire drill was conducted December 2025. The facility completes fire/emergency drills monthly. The fire alarm and sprinkler system was last inspected September 2025. Fire extinguishers were observed to be last charged on 11/2025. Facility's smoke and carbon monoxide detectors and sprinkler system were last inspected September 2025. Water temperatures measured at between 109.2 and 113.4 degrees (F) which is within acceptable range of 105 to 120 degrees F. Bathrooms have non-skid surfaces and grab bars at the toilet and shower areas. - At 10:51 AM, LPA conducted a file review of ten staff and ten residents. Residents receiving hospice services had a care plan that appears to be accurate to services being provided. All residents' care plans seems to have a person-centered approach and they are updated. Medical assessments are current and included a description of any known behavioral expression. All staff have current 1st aid/CPR certificates updated and required training hours complete. Jeff Brenner, administrator certificate 6068069740 expires on 1/17/2026. A records check found that documentation has been submitted and certificate is pending. Medications and medication records were reviewed. ED agrees to submit updated documents by 1/30/26: (LIC500) Personnel Report & Liability Insurance. No deficiencies cited today. Exit interview conducted with ED and copy of report was given.