Routine inspection·March 26, 2025

Licensing Program Analysts (LPA) Zabel Chochian arrived unannounced to conduct a required annual visit. Upon arrival, LPA met with Executive Director, Jeannette Ruggiero, Assistant James Mackay, and Assisted Living Director, Shaulett Dela Cruz. The reason for the visit was stated. Entrance interview conducted and check list provided. At approximately 12 p.m., LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. COMMON AREAS: The facility is a two story building; units are designated for assisted living residents on the first and second floor, and a separate unit on the first floor is designated for dementia care. There were no obstructions and/or tripping hazards observed. The facility maintains a comfortable temperature. The fire extinguishers were charged and last serviced 04/19/2024. Smoke Detectors and Carbon Monoxide detectors were tested by Fire Protection Inc. on 12/20/2024; all were found functioning properly. Facility elevator was operating properly. There are four (4) stairwells that all have emergency evacuation chairs. ACTIVITIES: Planned activities are offered, and the activity schedule was posted. Activity rooms and common spaces appeared clean and in good repair. Currently group activities are on hold due to the outbreak. KITCHEN: At the time of the visit, there was a sufficient supply of perishable and nonperishable food. Refrigerator, freezer, and pantry area were observed; food labels were inspected and checked for dates and expiration dates, and food labels had dates clearly marked. The facility also has an emergency supply of food and water. The weekly menu was posted by the dining room entrance. Appliances appeared to be clean and in operable condition. At this time due to the outbreak dining room is closed and meals are being served to residents in their room. Continued on LIC 809C... BEDROOMS: LPA toured seven randomly chosen rooms; two (2) in memory care, and five (5) in assisted living. Rooms appeared clean, well kept, with sufficient lighting and appropriately furnished. Five (5) out of seven (7) residents were interviewed during the tour. RESTROOMS: Restrooms on all floors were clean and sanitary. Restrooms were fully stocked with supplies. The hot water temperature was tested on all floors and ranged from 107.5- and 120-degrees Fahrenheit. OUTSIDE AREAS: LPA observed appropriate outdoor furniture with a covered shaded area for residents. There was an enclosed patio for residents who reside in the memory care unit. MEDICATIONS: Medications are centrally stored in the medication room; there is a medication room on each of the two (2) floors. Random resident medication review conducted; PRNs observed with physicians order on file; residents medications observed recorded on the centrally stored log; Medications appeared to be given as prescribed . Some records were missing start dates; staff recorded the start dates from the bubble pack. In-service training provided. RECORDS REVIEW: LPA reviewed seven resident records at approximately 3p.m. All seven (7) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, personal rights form, and current needs and services plan. All records were in order. Five (5) personnel files were reviewed at approximately 4:30 p.m. for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records observed in order. The facility has a comprehensive disaster plan. Emergency disaster drills are conducted quarterly as per regulation; the last one being a fire drill and was conducted in 01/2025 (1st shift); 2/2025 (2nd shift); third shift is scheduled in 3/2025. No citations issued during today's visit. Exit interview conducted. Copy of report was provided.