Routine inspection (multi-day)·December 6, 2023

At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 Year visit and met with Executive Director/Administrator Shannon Brown, and Health and Wellness Director Melanie Fenn. Upon arrival, LPA was informed that there were 67 Residents in care and 9 staff members on-site. At approximately 9:45AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA reviewed staff files, resident files and resident medications. Files were found to be well organized, thorough, and contained the required documentation. Staff files had current First Aid and CPR certification. Medication was found to be centrally stored and secure. LPA conducted interviews. LPA requested the following documents to update facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610D) Updated Personnel Report (LIC 500) Register of Clients/Residents (LIC 9020) Updated Liability Insurance Facility Documents to be submitted to Community Care Licensing (CCL) by due date of Saturday, 01/06/2024. Exit interview conducted. Copy of report discussed and provided to Administrator/Executive Director. Signature on form confirms receipt of documents.