Follow-up·February 9, 2024

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced Case Management. LPA met with Sev Tienda and explained the purpose for the visit. Today's visit is to observe the delayed egress system and the two exit doors that have been approved to remain locked per the Approved Fire Safety Request (STD850) dated 6/1/21. Details on this approval state, "FACILITY IS LICENSED TO SERVE 200. NON-AMBULATORY RESIDENTS AGE 60 AND ABOVE. HOSPICE WAIVER APPROVED FOR 6 RESIDENTS. MEMORY CARE UNIT APPROVED FOR 12 RESIDENTS. FACILITY IS APPROVED TO LOCK BOTH EXTERIOR DOORS ON THE PERIMETER GATES IN THE MEMORY CARE UNIT/ HACIENDA BUILDING" , with a special comment by the approving inspector Smith stating "approved to lock/secure 2 exit gates" . There are currently 10 Residents in the Memory Care/Support Unit "Hacienda Building". Delayed egress system was tested and is working. All walkways around the Memory Care/Support Unit "Hacienda Building" unit were clear of hazards. The facility has 3 entrance/exits that lead to the front of the Hacienda Building, and 2 exits that lead to the back patio. The gates that will be locked/secured are the metal gates in the exterior of the building that wrap around the back yard/patio area. There is one gate on each side of the building. These gates are secured with a metal or rubber wire and are able to be opened by staff in the case of an emergency. There were no deficiencies cited on today's visit. Exit interview and copy of report and license has been provided to Wellness Director Sev Tienda