Routine inspection·August 22, 2025

At approximately 9:45 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and met with Theresa May Jones, Administrator. Facility is a Residential Care Facility for the Elderly (RCFE) with twenty-six (26) residents in care, all of whom are assisted living residents. Facility has a Hospice waiver for four (4). At approximately 11:15 AM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a three story building with all assisted living residents on the main floor. Facility was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There are shaded seating areas throughout the campus with outdoor space for activities. LPA observed residents in common areas watching TV, visiting with people outside, or eating in the dining hall. Residents go to the Member Services building for activities and to use the library and computers. Additionally, residents go to the main dining hall for their meals but snacks are made available in the Day Room and Deputy Office around the clock. Continued on LIC809-C... Continued from LIC809C... Smoke and carbon monoxide detectors, sprinklers, and fire alarm were tested during the facilities recent fire inspection in 06/2025. Fire extinguishers were observed fully charged and were last inspected 02/2025. Emergency Disaster Plan was reviewed and updated 07/2025. Facility conducts quarterly disaster drills with the most recent drill conducted 08/2025. Facility is quipped with an emergency lighting system and has a supply of flash lights. Facility's first aid cart was inspected and is stocked with the required items per regulation. At approximately 12:45, LPA conducted file review of five (5) resident files. Five (5) of Five (5) resident files reviewed contained all the required documentation. Administrator states that the residents, medical records department, and the Ambulatory Care Clinic (ACC) coordinate medical and dental appointments as well as transportation to and from appointments when residents have the need. LPA will return at a later date to conduct staff file review and medication and medication records review. Facility does not maintain or manage P&I cash resources for residents. No deficiencies cited during today's inspection. Exit interview conducted with Administrator whose signature on form confirms receipt of documents.