Routine inspection·March 17, 2025

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced annual required visit. Upon entry, LPA was greeted by Gloria Gourlay, Administrator, and informed them of the purpose of the visit. At the time of the visit, there were eight (8) staff members and thirty nine (39) residents present. Facility Overview: The facility is a two-story building with forty six (46) bedrooms and forty six (46) bathrooms. There are no pools or known firearms on the premises. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. Laundry equipment located in a room with locked gate was in good working condition. Sharp and dangerous objects were securely locked and inaccessible to residents inside the kitchen with locked gate. LPA reviewed fire marshal inspection report dated 7-2-2024 with no deficiencies found. Hot water temperature was 107°F. There are 16 fire extinguishers. LPA inspected 4 random fire extinguishers located in the hallways, and all had current inspection tags. Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods. Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate. Continued on LIC809-C.... Record Review and Resident/Staff Files: LPA reviewed files for four (4) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Eight (8) resident files were reviewed and contained all required documentation. Health-Related Services/Incidental Medical Services: All resident medications were securely locked inside nurse's room. LPA reviewed medications for four residents, confirming that all medications were listed on the Medication Administration Record (PointClickCare) and accounted for. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 11-26-2024, which met department requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed and provided.