Routine inspection·February 20, 2025

On 2/20/25, Licensing Program Analyst (LPA) Arvin Villanueva conducted an unannounced annual required visit, with the use of the CARE Inspection Tool. LPA met with Assistant Executive Director, Brandee Butler, and explained the purpose of today’s visit. Adminstrator Loreen Hickman was not available during this visit. The facility is currently licensed to serve 47 ambulatory and non-ambulatory elderly residents. The facility is approved for 5 hospice residents. LPA and Brandee inspected the facility’s physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, parlor area, common TV area, activity area and outside of the facility. The facility is a two-story building located in a residential neighborhood. There were no bodies of water were observed at this time. Entrance, exits and hallways were observed to be clear of obstructions. LPA observed an evacuation chair located near the entrance door by the reception area. Facility has one elevator and was observed to be operational at this time. The facility common areas, including the activity room, dinning hall, parlor/living room, and hallways, were observed to be organized and free from debris. LPA inspected 5 resident apartments. LPA observed beds and bedding supplies were in good condition, adequate lighting was provided, and sufficient storage for the resident's personal belongings. Bathrooms were operational and adequately supplied including with grab bars and non-skid flooring. Hot water in 5 of 5 resident bathroom faucets were measured between 108 and 113 degree Fahrenheit. Smoke detectors and carbon monoxide were observed in each of the inspected apartments. The kitchen was inspected, and was observed to be clean and free of clutter. Facility maintains a sufficient 2-day perishable and 7-day non-perishable food. Room temperature was maintained in the facility at 71 degrees F in the hallway and 72 degree F in one resident apartments. Two fire extinguisher were inspected and both were serviced on 11/26/24. Medications were observed to be stored in the locked medication room near the the reception and office area. {1 of 2} Medications were observed to be locked and inaccessible to residents in care. Sharp objects, poisonous substances and other dangerous items were observed to be inaccessible to residents in care. During this visit, LPA conducted an audit of facility files, 7 resident files, and 5 staff files for regulatory compliance. The 7 resident files reviewed contained to documents including updated admission agreements, medical assessments, and needs and services plan as required. 5 of 5 staff were noted to have criminal background clearances and associated to this facility. The 5 staff files reviewed contained documents including health screening, TB results, current first aid, and initial and ongoing training. Facility conducts quarterly fire drills and last drill was conducted in November 2024. LPA requested an updated copy of LIC 308, LIC 500, and liability insurance certificate to be sent to the Department by 2/21/25. At this time, no citations are being cited. An exit interview was conducted and a copy of this report was provided. {2 of 2}