Routine inspection·April 30, 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) Rosa Ayala and explained the reason for the visit. The facility is a three story building which consist of 30 units on the first floor reserved for memory care residents, and 16 additional units on the second floor for memory care residents. The capacity of the facility is 180 non-ambulatory and a hospice waiver for thirty five and bed ridden waiver for thirty five. There are currently a total of 117 residents, forty two of them are in memory care, and eleven on hospice. Rosa Ayala's Administrator's Certificate expires on October 23, 2024. LPAs observed the PUB 475 poster (See Something, Say Something Poster) posted by the resident mail box. The PUB 475 poster posted is 20" X 26." Around 9:49 AM, LPAs and ED Ayala 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 three floors of the facilities. LPAs and ED toured the resident rooms in memory care unit area. LPAs inspected twelve 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 twelve resident rooms inspected measured 112 degrees Fahrenheit to 118.2 degrees Fahrenheit. LPAs observed residents participating in exercises in the activities room in the memory care area. There is fitness room and activities room for all residents. There is an outdoor courtyard for residents to sit outside. In the outside area there is a garden for residents to plant things. Also there is a pool area with a gate. Residents can utilize the pool as long as they are accompany with a staff who is water safety certified or a family member. In the summer they have water aerobics. 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 March 13, 2024. The fire safety system is inspected annual every year by an outside agency, the last inspection was 9/19/23. Around 11:10 AM after the facility tour, LPAs reviewed twelve resident files with no discrepancies. All resident files had the required documents. Afterwards LPAs reviewed ten staff files with no discrepancies observed. Annual Report cont on LIC-809C All staff files reviewed had current CPR/First Aid training. At around 2:30 PM, LPAs inspected medication and medication administration records (MAR) for selected 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