Routine inspection·August 12, 2025

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced required 1-yr inspection. LPA met with Liyon O'Quinn, Executive Director and Milka Osorio, Director of Health Services and explained the purpose of the visit. The facility is licensed to serve (285) ambulatory residents, (14) non-ambulatory residents, hospice waiver for (14). Rooms 100, 101-108, 110, 11, 113, 115, 117 are approvided for non ambulatory. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility has Infection prevention and control plan, process, procedures and training plan. Staff are trained on the emergency infection control plan and following hand hygiene techniques. Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a sign-in station located in the main entrance lobby. Emergency and disaster plan was completed and up to date. Operational Requirements: Infection prevention and control plans have been added to the Plan of Operation. Liability insurance in the amount of ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires on 01/01/2026. Fire and disaster drills are conducted monthly, and the last drill was last conducted on 07/31/2025. Care and supervision to meet the residents needs was observed. Special equipment and supplies to meet the residents with special needs were observed. Physical Plant/Environment Safety: The facility contains multiple buildings such as the Administration Building (Main building), Kingsley Manor Care Center, Margaret Hall, Dining Hall, Leitzell Hall, Holly Cottage (Activities area) and the White house. The facili ty has (5) separate buildings th at house residents, a dining room, a kitchen and several public restrooms located throughout the facility. LPA toured random resident rooms in different buildings and observed each bedroom to contain the necessary furnishings and linens. Bathrooms were observed to be clean and equipped with operational grab bars. The signal system is placed in various locations and is interconnected with the Fire Department. LPA checked the hot water temperature in random resident rooms and measured within 105 – 120 Degrees F as required by Title 22 regulations, Additionally, the facility maintains a log of the water temperatu re. The common areas, covered patio, movie theater, family room and the main activity room are all located on the top/sixth floor of Leitzell Hall, while the main laundry for residents is in the basement of the building. Every building has a medication room , and certain buildings have elevators. The facility has cameras in the common areas. The facility is gated with a parking lot that is connected to the main building, and the grounds are well landscaped. The facility has an emergency sprinkler system throughout. All the fire extinguishers were observed to be fully charged, last serviced on 03/24/2025 and in compliance. During the tour, kitchen was inspected, knives, cleaning supplies and disinfectants were kept locked and inaccessible to residents. During lunch preparation for residents, kitchen staff were observed wearing hairnets and disposable gloves . Exit doors are free of any obstruction and there are no pools or large bodies of water. There are no security bars or weapons on the premises. ***CONTINUED ON LIC 809-C**** Staffing: A total of (107) staff members on the roster list including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Night shift staff are trained and able to assist in care and supervision of the residents in the case of an emergency. Personnel Records-Training: Ten (10) staff files were reviewed and confirmed fingerprint clearances, health screenings, vaccinations and 1st Aid/CPR training are current. One of the staff (Staff #3) does not have a current CPR/First aid training certificate, expired July 2025. Administrator certificate is valid and will expire on 10/11/2025. Residents Rights-Information: The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman. Notice of visiting policy is posted. The facility provides internet services to all residents and have access to the facility phone. Planned Activities: Activities calendar is up to date and posted. The facility has a Resident Council/Club and meet on a monthly basis. Facility provides equipment and sufficient space to accommodate both outdoor and indoor activities. Food Service: Director of dining services and LPA toured the kitchen, dining area and food storage in the basement. Sufficient food supply is stored in the kitchen, pantry areas and basement consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed. Kitchen staff workers were observed to be wearing hairnets and using disposable gloves while working and preparing food. Incidental Medical & Dental: Medications were reviewed containing 30-day supply of medications. Medications are centrally stored, properly labeled and are in their original containers. First aid kit is maintained. Some residents get regular visits from their respective physicians. Resident Records-Incident Reports: A total of (10) resident files were reviewed. They contained Admission Agreements, current Physician's Reports, Pre Placement Appraisal, TB clearance, Functional Capability Assessment, Identification & Emergency Information, Physician's Orders, Medical Consent, and Medication Records. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and there is an evacuation chair at the stairwell. Residents with Special Health Needs : Director of Health Services stated that the facility retains residents with dementia if they are determined to be appropriate for the facility. No deficiencies cited. Technical violation issued. Exit interview held and a copy of the report was provided to Liyon O'Quinn, Executive Director