Pre-licensing visit·August 10, 2021

Licensing Program Analyst (LPA) Tuesday Cabiness met with Executive Director/Administrator Shakeb Rafat for a Pre-Licensing visit. Fire clearance was approved on 03/09/2021, for non-ambulatory and no delayed egress system. There is a hospice waiver for (10), with a capacity of (136). The current census is (109). Upon entry, LPA was COVID screened, with temperature check and responded to a questionnaire. Executive Director informed LPA, there are no positive cases, and 100% of staff and residents are vaccinated. All staff and residents are required to wear face masks in common areas; except residents can leave them off in private rooms, or when eating. There are hand sanitizing stations throughout the facility. The facility consists of a (4) story building with underground parking. Activity and daily menu were visibly posted, as well as Licensing and COVID signs. There are resident rooms on each floor; and (2) bathrooms: (1) for staff and the other for residents. LPA inspected all areas of the facility: Administration, medication room, game room, fitness center, outdoor patio, library, dining room, kitchen, beauty salon, and resident rooms and bathroom. Each room is provided appliances, such as stove, refrigerator, microwave, washer/dryer, and basic cable services. There are (2) types of signal features used. Facility uses Phillips Life-Line alert pull chords in resident restroom, kitchen and all residents carry a pendant. Caregivers are provided pagers, that identify when an alarm is signaled. The signal is also heard by the receptionist desk computer. Facility has also installed pull chords in the public restrooms. Facility has an emergency generator that will keep lights, phones, elevators, and main food freezers operating during power outages. The main kitchen and dining room are located on the (1 st ) floor. Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. Facility has adequate perishable and nonperishable food and water supplies. Medications were kept in the medication room with locked cabinets inaccessible to residents in their rooms. The facility staff's an LVN who handles training of caregivers including medication technicians. There is an in-ground spa that is gated and kept locked and inaccessible to residents. The physical plant inside and outside was free from obstruction, with clear passageways. The facility is currently in compliance with Title 22 regulations. Exit interview, and copy of report issued to Executive Director.