Routine inspection·January 27, 2025

Licensing Program Analysts (LPAs) Joseph Alejandre, Hanna Gough and Fred Arias made an unannounced visit to conduct the required annual inspection. LPAs met with Executive Director (ED) Brian Keys and explained the reason for the visit. Facility consists of two buildings, one is for Assisted Living (AL) and the other for Memory Care (MC). The capacity is 195 non-ambulatory of which ten can be bedridden and a hospice waiver for eight. Brian Keys' Administrator's Certificate expires on February 18, 2025. LPAs observed the PUB 475 poster (See Something, Say Something Poster) posted in the main entry way is 11 1/2 by 17 1/2. The PUB 475 poster posted by the mailboxes is 20" X 26." LPAs and ED Keys 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 observed an emergency food and water supply stored in a storage room. LPAs observed that the refrigerator and the freezer had a temperature log posted in the kitchen. The refrigerators and freezers are at the required temperature. 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 15 resident rooms. All resident rooms had the required furnishings. All resident bathrooms were clean and operational. The hot water in the fifteen resident rooms inspected measured 107.2 degrees Fahrenheit to 115.5 degrees Fahrenheit. There is a fitness room and activity room for AL residents. There is a movie theater, music room and activity room from MC residents in the MC building. There is an outdoor courtyard in both buildings for residents to sit outside. 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 January 4, 2025. The delayed egress tested operational in the MC Building. The fire alarm and life safety system was inspected and tested operational on July 5, 2024. LPAs observed medications are kept secured in a medication cart that is locked in a medication room. LPAs observed that the First Aid Kit in the medication room has all the required elements. LPAs interviewed staff and residents. LPAs reviewed 5 staff files with no discrepancies observed. All staff files reviewed had current training and CPR/First Aid training. LPAs observed the resident library has a computer with internet access for resident use. LPAs tested the call system in both buildings, the average response time was 4 minutes. LPAs reviewed 16 resident files with no discrepancies observed. LPAs inspected medication and medication administration records. No discrepancies observed. All resident files had the required documents. No obstacles or hazards were noted inside or outside of the facility. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.