Routine inspection·October 21, 2024

Licensing Program Analysts (LPAs) Joseph Alejandre, Brandon Lopez, and Nancy Guillen made an unannounced visit to conduct the required annual inspection. LPAs were greeted and granted entry by staff. LPAs met with Executive Director David Armour and explained the reason for the visit. The facility is licensed for a capacity of 220 of which 120 can be non-ambulatory, approved for 8 bedridden and a hospice waiver for 25. Facility is one building with 4 stories. The building has a central courtyard with a pool which is fenced. LPAs and the Executive Director toured the facility. LPAs observed the fireplace in the lobby is screened. The See Something, Say Something Poster is posted in the mail room and is not in the main entry way of the facility. LPAs toured the kitchen and dining room. LPAs observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPAs observed the kitchen is clean and organized. LPAs observed the refrigerators and freezers are kept at the required temperatures. LPAs toured 11 resident rooms. LPAs toured rooms on each level. LPAs observed each stairwell has an emergency evacuation chair. LPAs observed all rooms had the required furnishings. LPAs observed in the rooms inspected that all the bathrooms are clean and operational. Hot water measures between 110.0 to 116.6 degrees Fahrenheit. Medications are kept locked in the med room in a locked medication cart. The memory care unit has their own med room and medication cart which is kept locked. LPAs and the Executive Director toured the memory care unit which is on the first level. The memory care unit uses a secured perimeter and has delayed egress exits. LPAs tested 4 delayed egress exits and all exits operated properly. No obstacles or hazards observed in the memory care unit. The facility has activity rooms and sitting areas on each floor. There is an outdoor patio on the first level which has a pool. The pool fence is 5 feet tall and kept locked and is inaccessible to residents. LPAs observed the facility has emergency food and water stored in a storage room. No obstacles or hazards observed in the patio. There is shaded seating in the patio. No obstacles or hazards observed in the facility. LPAs reviewed resident medications and files. LPAs reviewed 11 resident files, no discrepancies observed. LPAs reviewed 10 staff files, no discrepancies observed. Staff had the required training and is associated to the facility. The last emergency drill took place on October 17, 2024. The fire suppression was tested on April 26, 2024. The facility is operating within their license. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.