Routine inspection (multi-day)·April 9, 2025

Licensing Program Analysts (LPAs) Quoc Huynh and Emily Peraldi arrived unannounced at 10:20AM for a Case Management Annual Continuation visit from 03/12/2025. The LPAs met with Executive Director (ED) Nancy Nelson and explained the reason for the visit. Entrance interview conducted. During the visit, LPAs conducted review of the following: RECORDS: Personnel records were reviewed at 11:00AM. The LPAs reviewed six personnel records for, but not limited to job application, health assessments, TB results, criminal record statements and clearances, and first aid/CPR certification. Staff files reviewed were in compliance with regulation at this time. Resident records were reviewed at 11:55AM. The LPAs reviewed five files for, but not limited to admissions agreements, medical assessment, and updated appraisals. Resident records reviewed were in order at this time. At 12:30PM, the LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility was observed to be in compliance at this time. Fire alarm/sprinkler system was last tested on 03/21/2025 by West Coast Fire with a follow up to be scheduled to close the inspection. Report Continued on LIC 809-C MEDICATION: Medication reviews occurred at 12:50PM (Memory Care unit) and 1:25PM (2 nd floor Wellness Center). The LPAs reviewed medications for four residents during the visit. Medications are centrally stored and inaccessible to residents in the Wellness Center located on the second floor. Four out of four resident medications reviewed were documented and stored in compliance with regulation at this time. Four residents and two staff were interviewed. No complaints noted. No deficiency cited. Exit interview conducted. A copy of the report was provided.