Routine inspection·April 25, 2024

Licensing Program Analysts (LPAs) Kimberly Lyman and Michael Tea made an unannounced visit to conduct the required annual inspection. LPAs met with Executive Director (ED) Foudil Manadi and explained the reason for the visit. Facility consists of two buildings in which one is for Assisted Living (AL) and the other for Memory Care (MC). The capacity is 150 non-ambulatory and a hospice waiver for eight. There are currently a total of 103 residents, thirty three of them are in memory care. Foudil Manadi Administrator's Certificate expires on January 28, 2025. LPAs observed the PUB 475 poster (See Something, Say Something Poster) posted in the front entry way and another one posted by the resident mail box. The PUB 475 poster posted is 20" X 26." Around 9:46 AM, LPAs and ED Manadi toured the facility. LPAs observed the kitchen is clean and organized. There is a two day supply of perishable food and a seven day supply of non-perishable food on-hand in the kitchen. LPAs and ED toured resident rooms on the first and second floors in AL. LPAs and ED toured the resident rooms in the MC building. LPAs inspected ten resident rooms. All resident rooms had the required furnishings. All resident bathrooms were clean and operational. LPAs tested the emergency pendants and observed the staff came promptly when alerted. The hot water in the ten resident rooms inspected measured 102 degrees Fahrenheit to 119 degrees Fahrenheit. LPAs observed residents participating in dancing exercises and memory games. There is fitness room and activities room for all residents. There is an outdoor courtyard in both buildings for residents to sit outside. Memory Care outdoor area had vegetable and fruit garden. There are fire extinguishers on every floor and all fire extinguishers are fully charged. LPAs observed emergency evacuation chairs in each stairwell. The last emergency fire drill was conducted on April 13, 2024. The delayed egress tested operational in the MC Building. The fire safety system is inspected annual every year, the last inspection was 4/19/23. The fire safety system is monitored electronically throughout the year. Around 11:00 AM after the facility tour, LPAs reviewed ten resident files with no discrepancies. All resident files had the required documents. Afterwards LPAs reviewed ten staff files with no discrepancies observed. All staff files reviewed had current CPR/First Aid training. Annual Report cont on LIC-809C All direct care staff files reviewed met training requirements. At around 1:30 PM, LPAs inspected medication and medication administration records (MAR) for ten residents. No discrepancies observed. LPAs observed medications are kept secured in a medication cart that is locked in a medication room. LPAs observed the first aid kits to have all the required components and a first aid book at hand. LPAs interviewed staff and residents. No obstacles or hazards were noted inside or outside of the facility. Based on the observations made during today's visit, no deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.