Routine inspection·May 2, 2025

On May 2, 2025 Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required annual visit using the CARE Inspection Tool. LPA was greeted by staff and granted entry after stating the purpose of the visit. Executive Director (ED) Luis Rodriguez was present to assist with the facility inspection on today's date. The facility is licensed for One hundred thirty nine (139) Non Ambulatory residents of which Ten (10) residents may be bedridden with approved hospice waiver for ten (10) residents. Currently, there are Five (5) Hospice residents present during today’s visit. Facility is a three story building with 93 units combined in both Assisted Living and Memory Care. At around 11:40 AM, LPA Tirre conducted a tour of the physical plant accompanied by Executive Director Luis Rodriguez, and the following was observed: Rooms which were inspected observed to be furnished Beds and bedding supplies were in operational condition, lighting was provided, and storage for the Resident’s personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured between 112.8 to 116.7 degrees F. A comfortable temperature of 71 degrees F. was maintained in the facility.. Residents were observed relaxing in common areas, eating in the dining room, and relaxing in common areas as well as relaxing in bedrooms. Memory care residents were observed engaged in eating lunch in dining area. The kitchen was inspected, and facility has required two (2) day perishables and seven (7) days non-perishable foods as well as supply of emergency food and water. Kitchen area was maintained with cleanliness. LPA Tirre observed facility refrigerator and freezer to be operational and met regulatory CONTINUED ON 809C requirements Storage areas for sharps objects and cleaning supplies were stored and not accessible to residents. Facility has multiple fire extinguishers. During today’s visit eight (8) fire extinguishers were observed to be fully charged and mounted. A review of the Medication Records Administration (MAR) was conducted, and LPA’ observed the records are in compliance. The medications were inaccessible to residents, centrally stored and maintained in compliance. All pathways, doorways, and emergency exits were observed to be free of obstruction. There were no bodies of water observed anywhere on the property. During the visit, LPA observed the facility's infection control practices. LPA’ observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted. LPA observed facility has a supply of Personal Protective Equipment (PPE). LPA observed First Aid Kit was maintained. A working landline phone was operational. Facility has operating smoke detectors and audible alarms which LPA observed Smoke alarms and carbon monoxide detectors were last serviced on 1/21/2025. The last fire drill was conducted on 4/29/2025.. LPA observed evacuation chairs located on top story stairwells. During today’s visit a review of eight (8) residents (R1-R8) service files and five staff (S1-S5) personnel files revealed to be complete. The facility has the current administrator's certification on file for Luis Rodriguez #70033677 Expiration 10/27/2025. No deficiencies during this inspection visit. An exit interview was conducted with Executive Director Luis Rodriguez, and a copy of the report was provided.