Pre-licensing visit·April 15, 2025

Licensing Program Analyst (LPA) Katie Brown arrived at the facility to conduct a Pre-Licensing Inspection. LPA met with Licensee Benjamin Donel and Administrator Jessica Pelaya. The facility has capacity for 300 residents. Per Fire Clearance, 290 Non-Ambulatory and 10 Bedridden. A hospice waiver has been granted for 10. The Independent (IND) and Assisted Living (AL) residents will reside in a mixed setting. The Memory Care (MC) is a designated portion of the building. The facility has designated 67 rooms as AL, 36 rooms as IND and 32 as MC. LPA began the tour by entering through the main entrance/lobby of the 2-story building. Required postings were observed and hung as required. Common areas throughout the facility were well lit with clear walkways. Furniture was observed to be properly spaced and in good condition. Flooring found to be intact throughout. Resident apartments (IND, AL and MC) were randomly selected and toured. LPA observed operating AC/Heating units, Smoke/Carbon Monoxide detectors. Bathrooms were in good repair with faucets delivering hot water. The facility currently has apartments “move in ready” on the first floor AL and IND living. In these rooms contained, required furniture, furnishings and linens were observed. There is a signal system in place which was operational. Hot water in rooms toured measured between 107 – 114 degrees Fahrenheit. LPA observed supply of paper products, bed linens, towels and personal hygiene/grooming products. The kitchen was observed to have both walk in and stand-alone freezers and refrigerators which were maintained at required temperatures. LPA observed supply of dishes, plates, utensils, and cooking items. Cleaning supplies and chemicals as well as knives and sharp items are properly stored. Appliances were found to be in working order. The kitchen was clean with floors and storage areas intact. LPA observed medication rooms on first and second floors. The facility has three locking medication carts which will be utilized in medication pass throughout the facility. The First aid kits contained the required items. Emergency food and water supplies were observed. The Fire Extinguishers were serviced 6/24/2024 by Independent Fire & Safety. Doors and passageways are unobstructed throughout the inside of the facility common areas. The elevators were tested and in working order. A laundry room was observed with new appliances and room for storage. Outside of the facility was toured. The grounds are well maintained with clear and defined walkways. There is a gated pool which was gated and locked as required. The following requirements have not been met at the time of this inspection: 1. Toilet grab bars need to be installed in resident bathrooms 2. All apartments were not found to be useable during the visit 3. Carpets were soiled in some areas. Carpet cleaning was in process during the visit 4. Delayed Egress system was not operable and under repair during the visit An exit interview was conducted with LIC and AD. It was explained that once the items above were complete and resolved, LIC will notify LPA Brown, and a subsequent inspection will be scheduled. The COMP III was not conducted during this visit. A copy of this report was signed and emailed to ben@sunsetequitygroup.com