Follow-up·August 8, 2024

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit at the facility to follow up on capacity increase request submitted to the department on 2/9/24. LPA met with Denise Sutton and explained the reason for the visit. The facility is currently licensed to serve 60 non-ambulatory residents over the age of 60, of which 5 residents may be bedridden and has a hospice waiver for 9 residents. The facility is located in a residential area and consist of a multi level building with a dining room, library area, a commercial kitchen, courtyard, activity area, several rooms, and patio. No changes have been done to the building. The capacity increase will take place by changing current bedrooms into shared resident bedrooms. The Fire Clearance was granted for 124 non-ambulatory residents over the age of 60 on 7/25/24. The facility does not serve dementia residents and does not have a memory care unit. LPA toured the facility with Denise Sutton and observed common areas and the following resident rooms: #101,116,123,230, 229, 208 randomly chosen. Room #230 was observed currently as a storage, with the closet doors removed, bathroom needs a sink cabinet door, and a toilet seat. Room #208 has a wall with a passageway which will be use for one resident to get to the bathroom and for the other resident to get to the room. Administrator will remove the items, place closet doors back and fix items in bathroom for room #230 and will remove the wall fully or half way in room #208 to avoid confusion on privacy or passageway regulations within 10 days and will submit pictures to the department. Plan of operation will be updated to provide information on meal times and changes due to the capacity in the dining room. LPA will return at a different time to follow up on the items above. Exit interview was conducted and a copy of this review was provided.