Routine inspection·September 23, 2024

Licensing Program Analysts (LPAs) Jessica Cho and Edward Kim arrived unannounced for the purpose of conducting the Required 1 Year Annual Evaluation using the Care Inspection Tool. LPAs were greeted and granted entry by Business Office Assistant (BOA) Samantha Stacey and explained the reason for the visit. LPAs met with Senior Executive Director (SED) Bob Fiorentino and Executive Director Selene Lopez. The facility is licensed to serve 430 residents of which 45 can be bedridden. Hospice waiver total care is 30. As of today, the resident census is 348 of which 19 are receiving hospice care. There are two buildings, north and south, with separate entries. The South Building, 1640, is comprised of an Assisted Living (AL) and Memory Care (MC). The North Building, 1650, is comprised of an AL. All common areas in both buildings were inspected which includes but is not limited to: Fitness Centers, pool/jacuzzi, Physical Therapy Center, Restaurant/Bar, emergency food storages, salon, library, movie theater, Rec Room, Activity Rooms, Dance Studio, Wellness Offices, dining rooms, and management offices. LPAs inspected twelve resident apartments which had all required elements. The residents' personal bathrooms were checked. Toilets, water faucets, and grab bars were secure. Showers were free of mold/mildew. The hot water temperature for the twelve bathrooms measured within range as per regulation between 107.4 and 119.6 degrees Fahrenheit. LPAs inspected the kitchens. Facility maintains ample supply of perishables and non-perishable food. The fire extinguishers were mounted, fully charged, and serviced on August 22, 2024. The smoke detector testing passed on May 6-7, 2024 per the fire alarm system inspection report conducted by VFS Fire & Security Services. LPAs toured the outside grounds. LPAs observed the courtyards which had sufficient shading and seating. The walks ways were clear of hazards. The swimming pool gates were secure. LPAs observed sufficient PPE and emergency disaster supplies including food/water in the storage rooms in both buildings. Emergency evacuation drills are conducted quarterly and facility is maintaining a log. Facility tests the generator monthly per the testing report dated August 20, 2024. LPAs observed the 'See Something, Say Something' (PUB475) poster in the correct size. Facility maintains a current liability insurance. LPAs conducted an audit of twelve residents' files and ten personnel files. No discrepancies noted. Medications were audited. No discrepancies noted. Staff and resident interviews were also conducted. Based on the observations made during today's visit, no deficiencies are being cited. An exit interview was conducted with Senior Executive Director Bob Fiorentino and Executive Director Selene Lopez, and a copy of this report was provided at the end of the visit.