Routine inspection·April 14, 2025

On 04/14/2025 at 9:30am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced annual required visit using the CARE Inspection Tool. At 10:15 am, LPA met with Administrator Ginger Enriquez. LPA Brown explained the purpose of today’s visit. The facility is licensed to operate for (230) non-ambulatory residents ago 60 and above with an approved hospice waive for (10) residents and dementia special program - facility has a delay egress unit for 68 residents. Currently, the facility has a total of 158 residents of which (53) are non-ambulatory residents, (105) are ambulatory residents. Also, the facility has (43) residents on home health, (2) on hospice care, (43) residents diagnosed with dementia , (33) residents are incontinent, (19) of the residents are in assisted living and (14) are in memory care The facility annual need are current. The facility has liability insurance with Notting Hill Risk Retention Grp (NAIC #17052): Policy Number ANH0000205-00 with effective dates 10/16/2024 - 10/16/2025. The facility is a two story structure located in a commercial neighborhood which consists of the following: (27) resident bedrooms in Arbor Unit and (119) resident bedrooms in Assisted Living. Each room has a bathroom in the unit, an activity room, a dining area, a kitchen, and outside patio area. Between the hours 10:23 am - 11:30am of LPA and administrator toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. The resident rooms inspected: in memory care room #4, #9, #10, #13, #24 and in room #36, #148, #163, and #206 in assisted living. All call buttons were in working condition. Bathrooms were operational with water temperature measured at 106.9 – 120 degrees F. Report continues on LIC 809-C. Between the hours of 11:30am - 3:15 pm, LPA conducted a records review of (11) resident records, (11) staff records, (11) Client Medication Administration Records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit and did not observed any discrepancies at the time of visit. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. On 11/14/2024, the fire department conducted an inspection for the alarm, smoke detectors and the fire extinguishers were charged and operable in each resident's room. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted. Due to time constraints LPA will continue the annual inspection at a later date. No deficiencies were cited during the time of visit, but deficiencies maybe issued at a later date. An exit interview conducted with Ginger Enriquez and a copy of the report is provided.