Routine inspection·July 8, 2025

Licensing Program Analyst’s (LPAs) Kimberly Ramirez, Blanca Gonzalez, and Sakinah Madyun conducted an annual inspection on 07/08/2025. LPAs met with Minerva Naranjo (Director of Health Services) and discussed the purpose of today’s visit. This facility is licensed to serve (252) ambulatory residents and (108) non-ambulatory of which (18) may be bedridden. There were two (2) bedridden residents receiving care during annual inspection. This facility may retain no more than twenty (20) hospice residents. There are fourteen (14) residents under hospice care, during annual inspection. Summer House Dementia Unit II is approved for (5) non-ambulatory residents with secured perimeter, locked gate and locked doors. There are currently twenty-two (22) residents in the Summer House Memory Care. The total number of residents at this facility is two-hundred and thirty-nine (239). See 809-C for continued report. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA’s observed carbon monoxide detectors and smoke alarms in hallways. Smoke alarms and carbon monoxide detectors were tested and observed to be operational. LPA’s inspected ten (10) rooms; of which five (5) in Summer House Memory Care and five (5) in The Lodge building of the facility. During inspection of Summer House Memory Care, LPA’s observed, combination locks on kitchenette refrigerators. Per Director of Health Services- Minerva Naranjo, resident#1 (R1) has a behavior of removing food or snacks from the refrigerator and placing the food item in random locations. LPA Ramirez will issue one (1) Technical Violation based on this observation. Director of Health Services- Minerva Naranjo instructed staff to remove all combination locks from Summer House Memory Care refrigerators. All resident bedrooms contained the required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. Facility maintains a monthly waterlog to record water temperature throughout the facility. LPA Ramirez observed postings encouraging proper hand washing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez tested emergency pull cord in room#103 at 10:59am, and staff arrived at 11:01am. LPA’s observed evacuation chairs in stairways. Food Service: LPA’s observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0 degree F (-17.7 degree C), and refrigerators with a maximum temperature of 40-degree F. (4 degree C). LPA’s observed facility weekly and daily menu, which is approved by the facility certified dietary manager. LPA’s observed kitchen staff preparing for lunch while wearing hair nets and gloves. LPA’s observed several dining room servers disinfecting tables and counters while wearing gloves and hair nets. SEE 809-C for continued report. Planned Activities: LPA’s observed a calendar for July of 2025 with various activities and outings for residents. LPA’s observed sufficient outdoor space in both assisted living section and in memory care. Residents Rights-Information: LPA’s observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility computers with internet access and a facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. LPA Ramirez observed evacuation chair in stairway. Last documented emergency drills were conducted on 7/01/25 during the AM, PM and NOC shifts. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez emergency food supply. Residents with Special Needs: Facility pool was observed to be inaccessible to residents with physical and mental disabilities. LPA’s observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA’s observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices and delay egress perimeters were observed to be in working order. Due to time constraints, LPA Ramirez will return at a later time to complete record review and interviews; required for annual inspection. No deficiencies were cited at this time. The Exit interview was conducted with Minerva Naranjo (Director of Health Services) and Administrator Robert Barton. A copy of this report was provided via email.