Routine inspection·January 9, 2025

At approximately 2:30PM, Licensing Program Analysts (LPAs) Felias and Stevenson arrived unannounced to conduct a Required 1 Year Visit and met with Executive Director, Kimberly Humphrey, and Health and Wellness Nurse, Angela Ramos . Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 70 non-ambulatory and bedridden residents. Of the 70 residents, 20 residents can be bedridden. Facility has an approved hospice waiver for 16 individuals. Facility is currently on a Non-Compliance Plan. Upon arrival, LPA's were informed that there were 43 residents in care and 22 staff members on-site. At approximately 2:50PM, LPAs reviewed Facility Staff Roster with Executive Director and found that all staff members on site were background cleared and associated to the facility per regulation. LPAs conducted a walk-though of the facility with Executive Director and observed the following: Facility is a 2 story building. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a infection control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Hot water temperatures for a sample size of 6 sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. LPAs unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date. No Deficiencies cited during visit. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.