Routine inspection·May 29, 2025

On 05/29/25, 10:00 am, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced annual visit. LPA met with Facility Administrator, Lori McKay, and reason for the visit was disclosed. Facility is licensed as a two story residence, encompassing 34 shared resident bedrooms, each with bathroom; three (3) public bathrooms are located in hallway areas. Fire clearance approved for sixty-eight (68) non-ambulatory residents; of which, twenty (20) may be bedridden. Hospice waiver for twenty (20) residents. At the time of this inspection, the facility occupied forty (40) ambulatory residents, and eighteen (18) non-ambulatory residents, six (6) of which are bedridden. Currently, four (4) residents are receiving hospice care services. At 10:35 am, LPA conducted a tour of the physical plant with the Facility's Maintenance Director, Saul Aranda, and observed the following: Facility’s main door is the primary access: Three (3) emergency exits are on the first floor, and two (2) emergency exits on the second floor. Exit routes are clear of obstruction. Screening area is located upon entrance. Delayed egress alarm sensors are present at all exit points and are working properly. Visitor sign-in sheet, hand sanitizer, gloves and masks are available. Room temperature is comfortable; wall thermostat displays a setting of 73 °F . , within the required range. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted on 3/29/2025. [Continued on LIC 809C] Fire Detection/Protection : Fire safety system is present in the facility. LPA observed multiple smoke and carbon monoxide alarms installed, hardwired, and interconnected. Fire system back up and tests are completed and documented on a biannual basis. Fire alarm system was tested and is working properly. Fire drill last conducted 3/29/2025. Fire extinguishers were observed on all floors of the Facility. All extinguishers were last serviced on 4/10/2025. Roof access is inaccessible to residents. Evacuation routes are clearly labelled and posted throughout the facility. Facility stairwells contain a required evacuation chair. Kitchen: LPA observed kitchen to be clean, with an adequate supply of perishable and non-perishable foods located in the refrigerator, freezer, and pantry. LPA observed a variety of fresh fruits, vegetables, meats, dry cereals, and desserts. Foods are properly labeled and stored. Knives and sharps are stored in a designated area of the kitchen. Kitchen is secured and inaccessible to residents. Laundry : Is located on sub-floor level. Laundry room, soaps, and other cleaning agents are stored and inaccessible to residents. Linen storage observed to have adequate supply of linen and towels. Commons: LPA observed upstairs and downstairs hallways, activity room, and dining room, finding them clean; furnishings observed to be in good condition. No obstructions, nor tripping hazards observed. Due to time constraints, LPA was unable to complete this annual inspection visit. LPA will complete at a later date. Exit interview conducted/Copy of report given to Administrator.