Routine inspection·April 23, 2025

On April 23, 2025, Licensing Program Analyst (LPA), Deborah Lee conducted an unannounced annual required visit using the CARE Inspection Tool. LPA Lee met with the Administrator Peggy Clark and the purpose of today’s visit was explained. The facility is licensed to operate for 262 non-ambulatory residents, of which 10 may be bedridden, ages 60 and over. The facility has an approved Hospice Waiver for 10. The census for today is 143. Physical Plant/Structure The facility is a large, two story, building located in a commercial neighborhood. The facility has a memory care unit and an assisted living unit; the assisted living unit consist of two floors which include resident rooms, common areas, dining area, kitchen, an outdoor shaded area, a laundry room, reception area and administrative offices. Memory care unit consist of two floors, resident rooms, dining area, common area, a theater, and delayed egress doors. The facility has a signal system with a switch board located in the reception area and is operational from all residential living units. Bedrooms LPA inspected seven ( 7) resident rooms, 146, 147, 148, 117, 311, 301, 303 and observed them to be clean and in good repair. LPA observed all rooms to be properly furnished with a bed, dresser, night stand, chair, and storage space for resident’s personal belongings LPA observed beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. The facility has an ample supply in a storage room for resident use. All rooms were observed with ample lighting. Bathrooms LPA inspected seven (7 ) resident bathrooms and observed them to be clean, operational, and meet Tittle 22 regulations. LPA found that in one of the hall bathrooms there was a missing toilet tank cover and a missing faucet handle. LPA observed storage area for residents’ personal hygiene products. The facility does have an ample supply of hygiene products available for residents. The water temperature in the resident’s bathrooms measured between 105-degrees and 120-degrees Fahrenheit. Common Rooms LPA inspected all common rooms in the facility and observed them to be properly furnished to accommodate all residents. LPA observed all walkway and hallway in the facility to be clean, clear, and free of obstructions and hazards. LPA observed all common areas to have ample lighting. The facility was kept at a comfortable temperature. LPA observed resident’s participating in activities and observed activity schedule posted in various locations of the facility. Kitchen LPA inspected the facilities industrial kitchen and observed it to be clean and sanitary. LPA observed all appliances to be operational and in good repair. LPA observed an ample supply of cook ware, dishware, and cutleries. LPA observed a 2-day supply of perishable foods, and a 7-day supply of non-perishable foods properly stored, packaged, and labeled. Page 2 of 3 Safety LPA observed multiple fully charged fire extinguishers throughout the facility last serviced on 2/25/25. The last inspection from Fire Alarm and Safety System was conducted on 10/31/24. The last emergency drill was conducted on 2/11/25. The elevator was last inspected and serviced on 8/2/24. The generator is ran and checked on a weekly basis; it was last inspected during the annual service on 4/5/25. LPA observed all required documents posted throughout the facility. The facility has a working landline telephone. Due to time restraints, LPA to complete inspection on subsequent visit. During today’s visit, there was 1 technical violation issued; see: LIC9102TV An exit interview was conducted with Peggy Clark Administrator and a copy of this report was provided. Page 3 of 3