Pre-licensing visit·October 2, 2024

On 10/2/24 Licensing Program Analyst (LPA) Alfonso Iniguez conducted a pre-licensing Change of Ownership evaluation for an RCFE facility type. Today’s pre-licensing evaluation was conducted with Executive Director: Brittany Kavanaugh. The licensee has applied for a license to serve (170) elderly residents age range 60 and over. The fire clearance is approved for (170) non-ambulatory of which (10) may be bedridden. Non-ambulatory and bedridden are only permitted on the first floor. Approved hospice waiver for (10). The facility consists of the following: The first-floor Lobby/receptionist area, Executive Director's office, Business office, copy area, Marketing office, living room, library/activity room, cafe/bistro/latte/water area, public/visitor restrooms, hair salon, life enrichment/activity office, storage rooms, dining room, commercial kitchen, staff restrooms, commercial laundry room, resident's laundry room, Director of Nursing office, medication room, employee's lounge, emergency food, mechanical room, electrical room, 3 storage rooms, and attached underground security parking garage. The second floor consists of resident's bedrooms and bathrooms, storage closets, and patio. The Memory Care Unit (MCU) consists of bedrooms and bathrooms, resident's laundry room, dining room/activity room, small kitchen, living room/TV room, shower room, Memory Care Coordinator office, small living room, storage room, and MCU patio. The third floor consisted of bedrooms and bathrooms, resident's laundry room, small living room/TV room. Report continues LIC 809C. The following was observed during this visit: MEDICATIONS There are locked storage areas for Resident medications. PHYSICAL PLANT Facility is clean, sanitary, and in good repair. Protective devices are in place. Indoor and outdoor passageways, stairways, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. Facility temperature is between 68°F. degrees and 85°F. degrees. Areas of potential hazard are well-lit. Smoke alarms operate properly. Carbon monoxide detectors operate properly. BEDROOMS There is a space for client’s own furniture that will accommodate a bed, a chair, a nightstand, a lamp, reading lights and a chest of drawers. BATHROOMS There is at least (1) toilet and washbasin per six (6) clients, family, and personnel. There is at least (1) shower or bathtub per ten (10) clients, family, and personnel. Hot water temperature is between 105F°. and 120F°. Bathrooms are located inside clients’ bedrooms. There are nightlights in the hallways outside non-private bathrooms. SUPPLIES There are client personal hygiene supplies to include soap, toothpaste, toilet paper, and comb. There is a sufficient supply of clean linens to permit weekly changing or more of client top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers, bath towels, hand towels, and washcloths. Report continues LIC 809C. FOOD SERVICE Dining room is near kitchen. Refrigerator(s) and freezer(s) are clean and large enough for the storage of at least two (2) days of perishable foods. Freezer is 0° Fahrenheit. Refrigerator is a maximum of 45° Fahrenheit. A seven (7) day supply of non-perishable food is present. There are enough tableware, tables, dishes, and utensils. There is enough equipment for the storage, preparation, and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean. RECORDS A review of (5) residents' service files and (5) staff personnel files was maintained in order. LPA reviewed (5) Medication Administration Records (MARs) and found no discrepancies. ADMINISTRATION The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Posting both sides of the Personal Rights form LIC 613 meets this requirement. Facility Visiting Policy is posted. Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings. ACTIVITIES There is an outdoor activity space with a shaded area and furnished for outdoor use. There is at least one common room available to clients for visitors. DELAY EGGRESS and SECURE PERIMETER Delay egresses are located on the 2nd floor memory care entry. Report continues LIC 809C. MISCELLANEOUS There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for commercial laundry. There is a space for clean linen storage and a separate space for soiled linen. There is an operating telephone available to clients. Emergency lighting and supplies to include flashlights with batteries. Copy of liability insurance will be email to LPA during this visit. During this pre-licensing inspection, LPAs did not find corrections were needed. LPA Iniguez conducted the Component III Orientation with the Licensee and copy of this report was provided. A copy of the facility evaluation report will be available to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with their assigned CAU Analyst. Exit interview conducted with Brittany Kavanaugh/Executive Director.