Routine inspection (multi-day)·May 27, 2025

Licensing Program Analyst(LPA) Mary Flores conducted an unannounced case management - annual continuation visit at the facility using the CARE inspection tool. LPA Flores met with Alex Alvarado Director of Health Services and explained the reason for the visit. LPA reviewed the following domains during this visit: Infection Control : Facility maintains a copy of infection control and was last reviewed on 6/13/24. Housekeeping staff were observed maintaining sanitizing procedures and Chef was observed doing proper hand washing. All staff have a TB clearance. Staffing: Administrator certificate was reviewed for Shaun Rushforth #6020615740 exp. date: 9/17/2024. Renewal documents were submitted to the department on 11/23/24. CPR/First aid training was observed for staff. One employee is on duty on the premises, administrator is on call,one employee is on call at the premises, additional staff are awake and on duty at night. Pendant call buttons were tested for 3 residents and they were respond within 5 minutes. Personnel Records/Staff Training: LPA reviewed 10 staff files. Files were available for review, except for chef's file. Chef is hired through Compass Community Living Hospitality Group (CCL) agency as a contractor for the facility. Files include; TB clearance, health screening, background clearance, personnel record, and training. Planned Activities: Facility has a Director of Life Enrichment to coordinate activities provided at the facility. LPAs observed various stations throughout the facility with puzzles, and reading areas. Memory Care Unit has a sensory area in addition to activities provided. (CONTINUED ON LIC 809C) Residents with Special Health Needs: Facility is serving 1 bedridden resident and 11 residents on hospice. Two hospices plans were reviewed. Facility has a fenced swimming pool, Dementia unit residents do not have access to knives/sharps, chemicals or medications, unless the physician allows them to have access to any. A delay egress system was observed and tested in the dementia unit. No deficiencies were not during this visit. Exit interview was conducted with Shaun Rushforth and a copy of this report was provided.