Most inspections found no deficiencies, including the most recent annual inspection on October 30, 2025, which was fully compliant with no issues noted. In July 2023, two complaint investigations substantiated problems related to eviction procedures: the facility failed to submit an eviction notice to licensing on time and issued an unlawful eviction notice lacking required details and language, though the eviction was later rescinded. These were isolated issues focused on documentation and resident rights, with no fines or enforcement actions listed in the available reports. Earlier inspections, including one in 2021 and another in 2024, were clean and showed compliance with all regulations. The facility appears to have addressed prior concerns, as recent inspections have been free of deficiencies.
An unannounced required annual inspection was conducted to evaluate compliance with licensing requirements for the facility.
Findings
The inspection found the facility to be in full compliance with no deficiencies cited. The physical plant, food service, documentation, emergency plans, and resident and staff files were all reviewed and found satisfactory.
Report Facts
Licensed capacity: 6Current census: 6Hospice waiver: 4Water temperature range: 105.2-113.9Date of last emergency drill: Oct 12, 2025
Employees Mentioned
Name
Title
Context
Fred Arias
Licensing Program Analyst
Conducted the inspection and authored the report
Ron Wilkes
Administrator
Facility administrator who assisted with the inspection
The visit was an unannounced annual required inspection conducted to evaluate compliance with licensing regulations.
Findings
The facility was found to be in compliance with all inspected areas including resident care, medication storage, physical plant safety, and documentation. No deficiencies were noted during the inspection.
Report Facts
Residents on hospice: 2Water temperature: 113.1Water temperature: 113.3Fire drill date: Jun 10, 2024
Employees Mentioned
Name
Title
Context
Michael Tea
Licensing Program Analyst
Conducted the inspection and authored the report
Ronald Wilkes
Administrator
Facility administrator who assisted with the inspection and reviewed the report
An unannounced case management visit was conducted in conjunction with complaint visit 22-AS-20230718163630 to investigate a complaint regarding failure to submit an eviction notice.
Findings
The facility failed to submit a copy of the eviction notice for Resident 1 to Licensing within five days as required, posing a potential health and safety risk to residents in care.
Complaint Details
Complaint visit 22-AS-20230718163630 was investigated. The deficiency cited was related to failure to submit eviction notice as required.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement has not been met as evidenced by failure to submit a copy of the eviction notice for Resident 1 within 5 days of issuance.
Type B
Report Facts
Capacity: 6Census: 6Plan of Correction Due Date: Aug 10, 2023
Employees Mentioned
Name
Title
Context
Kimberly Lyman
Licensing Program Analyst
Conducted the unannounced case management visit and investigation
Alisa Ortiz
Licensing Program Manager
Supervisor and Licensing Program Manager overseeing the visit
An unannounced complaint investigation visit was conducted in response to an allegation of unlawful eviction received on 07/18/2023.
Findings
The investigation substantiated the allegation that the facility issued an unlawful eviction notice to a resident's family without providing required documentation or specific facts. The eviction notice was later rescinded by the licensee on 07/26/2023.
Complaint Details
The complaint was substantiated. The allegation was unlawful eviction. The facility provided a 30-day eviction notice on 06/30/2023 without required documentation or proper language. The eviction was rescinded on 07/26/2023.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Licensee failed to set forth in the eviction notice the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons, and the notice lacked required department verbiage.
Type B
Report Facts
Capacity: 6Census: 6Deficiencies cited: 1
Employees Mentioned
Name
Title
Context
Kimberly Lyman
Licensing Program Analyst
Conducted the complaint investigation visit
Christine Wilkes
Administrator
Facility administrator present during investigation
An unannounced required 1 Year inspection was conducted to evaluate the facility's compliance with licensing regulations and operational requirements.
Findings
The facility was found to be clean, in good repair, and operating within approved capacity and conditions. No deficiencies were cited during the inspection. COVID-19 protocols and resident rights were observed to be in compliance.
Report Facts
Water temperature: 108.3Fire extinguisher expiration date: Nov 30, 2022Staff present: 2Residents present: 6Nonperishable food supply: 7Perishable food supply: 2
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