Post-licensing visit·November 17, 2023

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 11/17/23 to conduct a Post Licensing Inspection utilizing the CARE inspection tool. LPA met with the Executive Director (ED)/ Administrator and explained the purpose of the visit. . LPA and ED toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, 1 resident bedroom, med rooms, kitchen and dining, and The Gardens (Memory Care section). In the areas toured no immediate health, safety, or personal rights violations were observed. LPA reviewed resident files. Files were complete. LPA and ED discussed ensuring physician reports in a non-standard LIC 602 format be double checked for completeness of required information. Staff files were reviewed. Files are complete. LPA and ED discussed consolidating/ organizing files to have required forms and training in one place to help the review be more efficient. LPA requested resident roster and LIC 500 be submitted. No deficiencies are being cited as a result of todays inspection. Exit interview conducted. Report provided copy provided.