Routine inspection·December 6, 2023

Licensing Program Analyst(LPA) Christine Yee conducted an unannounced required Annual Inspection visit and used the complete CARE Inspection Tool. LPA Yee met with Evelina Papazyan, Administrator and the reason for today's visit was explained. The facility is a 3 storey residential building consisting of 30 bedrooms, a commercial kitchen, dining room, television room, lounge and a staff break room on the first floor. The second floor has 35 bedrooms, dining room, library and television room. 16 bedrooms out of the 35 bedrooms are designated for the dementia unit. The third floor has 36 bedrooms. The facility is fire cleared for 63 Ambulatory, 112 Non-ambulatory and 20 bedridden residents. Delayed egress is approved for the dementia unit. The following domains of the CARE Inspection Tool were reviewed on today's visit: Infection Control, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Records-Incident Reports, Resident Rights/Information, Planned Activities, Food Service, Incidental Medical and Dental. LPA Yee also reviewed the facility's Infection Control Plan, Emergency Disaster Plan, ten (10) resident files and seven (7) staff files. Per review of the nine (9)domains, 10 resident files and 7 staff files it was observed that all the required documents were in the residents and staff files and the hand washing procedures and requirements of each domain were being adhered to by the facility. The remaining three (3) domains: Physical Plant/Environmental Safety, Disaster Preparedness and Residents with Special Health Needs will be reviewed on a return visit. No citations were issued on today's visit. Exit interview was conducted with Evelina Papazyan.