Routine inspection·July 31, 2024

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with the Executive Director Tonya Reynolds and explained the reason for the visit. The facility has 2 buildings, building 1 is for assisted and independent living and building 2 is for memory care. Building 1 has 3 stories and building 2 has 2 stories. LPA and the Executive Director toured the facility. LPA observed the See Something, Say Something poster (PUB 475) posted in the main entry way of the facility. LPA observed the fireplace in the lobby living room is screened. Facility has a capacity of 200 of which 173 can be non-ambulatory, 10 may be bedridden and a hospice waiver for 20. LPA did not observe an emergency evacuation chair in the lobby stairway. LPA and the Executive Director toured the kitchen and dining room. LPA observed the kitchen is clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. The refrigerators and freezers were at the required temperatures. LPA observed the facility emergency food and water supply stored in a large utility closet. LPA observed all the fire extinguishers in the facility are fully charged. LPA observed that all of the stairwells in the facility had emergency evacuation chairs. The facility has multiple activity rooms and a theater for residents. There are games, puzzles and books for residents in the activity rooms and the theater plays movies every night for residents. LPA observed the facility has computers for residents to access the internet. There is also a fitness room for residents. LPA observed the medication room on the first floor is kept locked and medication is stored in a locked cart in the medication room. The first aid kit in the medication room has all the required elements. LPA toured 2 resident rooms on each floor in building 1. LPA toured 2 rooms on each floor in building 2 for a total of 10 rooms inspected. Smoke detectors/carbon monoxide detectors tested operational. Hot water measured from 105.0 to 116.6 degrees Fahrenheit in rooms inspected. LPA observed all rooms had the required furnishings. LPA tested the delayed egress doors in memory care (building 2) and all of the delayed egress doors are operational. LPA interviewed staff and residents. No obstacles or hazards observed in building 1 or building 2. The facility has an outdoor patio area which includes a pool which is fenced and kept locked. LPA observed a fountain and a koi pond in the patio area. This area is inaccessible to residents in memory care. No obstacles or hazards observed in the outdoor patio area. LPA reviewed 10 resident files and medications. No discrepancies observed. LPA reviewed 7 staff files. No discrepancies observed. All staff are background cleared and associated to the facility. All staff files reviewed had the required training. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.