Routine inspection (multi-day)·May 17, 2024

At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 Year visit and met with Executive Director, Sam Faye, and Regional Health and Wellness Director, Roschelle Factor. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance for a total capacity of 126 individuals, where 118 individuals can be Non-Ambulatory and 8 individuals can be Bedridden. Facility has an approved hospice waiver for 15 individuals. Upon arrival, LPA was informed that there were 71 residents in care and 25 staff members on-site. At approximately 9:30AM, LPA 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. At approximately 10:00AM, LPA reviewed memory care resident files. All files were found to be well organized, thorough, and contained the required documentation. LPA unable to complete Annual visit. Annual Continuation to be conducted on a later date. LPA to return to finish review of staff files and resident medication. 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 Updated Administrator Certificate Documents to be submitted to Community Care Licensing (CCL) by due date of 06/17/2024. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Administrator/Executive Director and Regional Health and Wellness Director. Signature on form confirms receipt of documents.