Routine inspection·March 12, 2024

Licensing Program Analyst (LPA) Wong conducted the Unannounced required annual inspection. LPA arrived unannounced and met with Administrator Mary Mims-Burris and assisted with the visit. The purpose for the visit was explained. The facility is licensed for residents ages 60 and over. The fire clearance is approved for 49 ambulatory and 111 non-ambulatory. Currently, the facility has 11 hospice waiver residents and 3 home health residents. On the above date, LPA completed the domain of Physical plant and environmental safety and food service today. Physical Plant and Environmental Safety: The facility is a three story building. The first floor includes memory care unit and assisted living resident's rooms, main lobby, administrative office, Bristol, wellness director office, two activity rooms, resident coordinator office, assistant director office, Chart room, Library, Multi-purpose room, resident mail box, community laundry room, dining room and facility kitchen. The 2nd floor includes laundry room, activity room, unisex bathroom and assisted living residents' rooms. The 3rd floor include laundry room, activity room, exercise room and unisex bathroom and assisted living residents' rooms. During the facility tour, LPA inspected Room #135, #106. #123, #117, #221, #216, #250, #353, #320 and #321 and they all have sufficient lighting and required furniture in the residents rooms. For the resident bathrooms, they are clean, sanitary and in a good working condition. All the residents bathrooms have the required Non skid mat and grab bar in the bath tub and toilet. LPA tested the hot water temperature and they are between 112.4 and 116.6 degrees F which are within the Tittle 22 regulation. The carbon monoxide detector is located in the laundry room and it's working properly. LPA reviewed the annual fire inspection and testing report via the state fire marshal and everything is working well. All the cleaning solutions and chemicals are locked in the janitor room and inaccessible to the residents. Facility has a telephone service on the premises. The backyard / rear grounds of the facility is well landscaped and the passageways are free of obstruction. The outdoor activity area is free of visible hazards and debris and the trash can or containers have the covered lids. Food service: Currently the facility has about 12 residents in the Assisted Living and 2 residents in the Memory Care Unit are required to have modified diet and LPA reviewed and observed the doctor's order. The facility has ample supply for two days perishable and seven days non-perishable food supply. The facility kitchen is clean and kept free of litter, rodents and insects. All food in the facility are stored properly. Due to time restraint and LPA was not able to complete the full inspection tool and interview residents and staff and LPA will come back at another time to complete. On today's date, there's no deficiencies were observed. Exit Interview and copy of the report was provided.