Routine inspection·March 4, 2025

At approximately 9:10AM, Licensing Program Analysts (LPAs) Deniz and Felias arrived unannounced to conduct a 1-Year Required Visit and met with Administrator/Executive Director, Angie Boucher-Turin. Facility serves older adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Facility has a total capacity for 160 residents and an approved fire clearance for 130 non-ambulatory residents, of which 40 residents can be bedridden. Facility has an approved hospice waiver for 20 individuals. Upon arrival, LPA was informed that there were 112 Residents in care and 29 staff members on-site. At approximately 9:50AM, LPAs reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 10:00AM, LPAs conducted a walk-though of the facility with Maintenance Assistant Eddie. LPAs observed the following: Facility is a 3-story building for Assisted Living and Memory Care. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for a sample size of 13 sinks were found to be within Title 22 Regulations of 105 to 120 degrees Fahrenheit. Facility's fire extinguishers were last inspected November 2024. Facility's fire and sprinkler system was last inspected March 2024. The next annual inspection is scheduled for next week, March 10, 2025. Facility's last emergency/disaster drill was conducted March 2025. Continued on LIC809 C… Continued from LIC 809… At approximately 12:00PM, LPAs reviewed 8 staff files. Files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. LPAs reviewed a sample size of 8 resident files and 6 resident medications. Resident files were found to be well organized, thorough and contained the required documentation. Medication was centrally stored and secure. During medication log review, LPAs observed that some medication date entries made by pharmacy were incorrectly logged. Per discussion with Administrator, facility is in the process of changing their pharmacy. Administrator's Certificate for Angela Boucher-Turin (7001386740) is current with an expiration date of 11/11/2025. No Deficiencies Cited during visit. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC610E- Disaster Plan Evidence of Liability Insurance Exit interview conducted. Copy of report discussed and provided to Administrator/Executive Director. Signature on form confirms receipt of documents.