Routine inspection·January 22, 2025

On 1/22/2025, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA met with Community Resources Manager (CRM), Lyssa Irani who was informed of the purpose of the visit. The facility is licensed to serve 99 non-ambulatory residents of which 10 may be bedridden. The facility also has an approved hospice waiver for 30 residents and LPA was informed 18 residents are currently receiving hospice services at the facility with one (1) deemed bedridden. LPA toured the facility with CRM. The facility is made up of a two-story building designated for assisted living and memory care. The memory care unit wings of the building are approved for delayed egress. CRM tested the delayed egress and LPA observed it to operational. Outside shaded seating is available for resident use. Indoor and outdoor passageways are free of obstruction. There are no bodies of water on the premises. LPA toured the kitchen and observed the facility has more than a two-day supply of perishable food and seven-day supply of non-perishable food items, which are stored in a safe and healthful manner. LPA also observed a cork board in the kitchen noting residents’ food allergies and dietary needs. The facility offers several activities and outings for resident leisure. Medications are secured in medication carts, only accessible to authorized personnel such as medication technicians. Resident files reviewed had updated physician's reports and signed admission agreements. LPA observed fire alarm systems, carbon monoxide detectors, and charged fire extinguishers throughout the facility. CRM contacted the facility's fire alarm company who reported the facility's fire alarms can only be tested by using a designed aerosol can containing a fine mist simulating smoke and spraying it directly towards one (1) of the smoke detectors to trigger the fire alarm. During the visit, the facility did not have the aerosol can available; therefore, facility staff was unable to physically test the fire alarms. As a result, LPA reviewed the facility's System Record of Inspection and Testing (SRIT) dated 3/14/2024, noting the fire alarms were last tested on 3/14/2024, by the facility's fire alarm monitoring company Addax Electric Inc. Per the SRIT, the fire alarms were found to be functioning properly. The facility's last fire drill was conducted on 12/17/2024. During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to CRM.