Routine inspection·May 7, 2026

On 05/07/2026, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct facility annual inspection, as well as issue final findings to the allegations to a complaint on a separate report. LPA noted that an additional finial finding to allegation of a separate complaint (29-AS-20251024145127) at the same facility location under a different Community Care Licensing (CCL) facility file number (565802467) that is was closed on 06/13/2025 and last updated on 10/28/2025. LPA met with Administrator, Brandy McCauley, announced who he is and the reason for the visit. The facility is two story and has one elevator. LPA conducted physical plant tour inside and out of the facility. LPA noted fire clearance for 121 non-ambulatory residents and delayed egress is approved for the memory care unit. The facility has ninety (90) private resident bedrooms and fourteen (14) shared rooms. Some shared rooms may be used as private rooms. None of the residents’ rooms have direct exits outside. There is a large dining room and industrial type kitchen located on the first floor and there are medication rooms on both the first floor and second floor where mediations are stored in medication carts and fist aide kits are stored. The common areas were appropriately furnished, and the lighting was adequate. There are activity rooms and television rooms with comfortable seating in assisted living and memory care. There was sufficient space to accommodate both indoor and outdoor activities. Night lights and emergency lighting were maintained in hallways and passageways to non-private bathrooms. There is a screened fireplace located in assisted living adjacent to the large dining room. The exterior passageways were clean and clear of any obstructions. There is a fenced outdoor area with a covered patio for memory care residents. There is a covered patio and outdoor area for assisted living residents. There are no bodies of water on the premises. There is a garage used for storage which remains locked at all times. Maintenance keeps their tools stored in the locked garage. The garage is a stand-alone building and not physically connected to the facility. CONTINUED on LIC809-C The facility smoke alarm system is hard wired. Facility has carbon monoxide detectors in common areas. The carbon monoxide detectors are tested by maintenance staff monthly. The fire sprinkler system, smoke alarm and fire doors were last inspected 4/16/2025 by fire marshal approved vendors. Maintenance checks smoke alarms and sprinkler systems monthly. Fire extinguishers are inspected by maintenance and annually by an approved vendor with the last annual inspection having been completed on 4/10/2025. Administrator stated that the next vender fire inspection is scheduled for May of 2026 pending bid approval. Administrator and LPA conducted a full physical tour of the facility and grounds and there were no violations noted. Administrator and LPA conducted a full review of the care tools modules and noted no violations or citations noted. LPA conducted file review of Resident and Staff files, Emergency Disaster Plan, Infection Control Plan, Centrally Stored Medication Records, Medication Administration Records, and Facility Liability Insurance coverage. LPA noted not violation and no citations during this full annual inspection. Exit interview, report read and report provided.