Routine inspection·May 15, 2025

On 05/15/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required inspection. LPA met with Executive Director Mariano Hernandez, where LPA explained the purpose of the visit. The facility is licensed with an approved fire clearance to serve 81 non ambulatory and 62 bedridden. There is a delayed egress in Building A (Life Guidance/memory care). The facility has an approved hospice waiver for (21) with (19) residents currently receiving hospice services. The facility currently has zero (0) bedridden residents. During today's visit LPA verified facility contact information and will update accordingly. Below is a summary of observations made during today's inspection of Assisted living census: (73) and Memory Care, census (28). In Assisted living the building consists of an Ice cream parlor, Nurse's station, library, kitchen, multi purpose room, beauty salon, art and crafts room and laundry room. LPA observed for there to be a missing screen on the window inside the laundry room located on the second floor. There was no citation issued as it was put back on during LPAs visit. In memory care (building A), consists of three wings (Wisteria court, Magnolia court and Rose court). LPA observed for there to be a dining area, salon, laundry room, and a kitchen- serves beverages and warms the food that is prepared in the main kitchen. LPA conducted a tour of the interior and exterior areas of the facility. The facility was observed to be clean, clutter and odor free. The food supply was observed to be sufficient as there was a two day supply of perishable and a seven day supply of nonperishable food items. The facility does have a pool located on the independent living side/building. It is open to all residents for use however, it is rarely used. The facility elevators were recently inspected February 2025. The facility has operable smoke and carbon monoxide detectors. LPA observed for there to be (4) fire extinguishers on each floor, that were last inspected on 12/22/24. Emergency disaster drills are being conducted on a quarterly basis, last drill was conducted on 2/26/25. In assisted living the medications were observed to be locked inside a medication cart that is stored inside the medication room located on the second floor. The facility utilizes an electronic Medication Authorization Record System. The same applies for memory care, as LPA observed to be locked inside a cart inside the medication room. The pull cords were tested in random resident rooms and were found to be operable. The hot water was tested in assisted living measuring at 111-113 degrees Fahrenheit. In memory care the water was tested and ranged from 116-120 degrees Fahrenheit. A file review was conducted and resident files were reviewed and were observed to have current resident assessments, and admission agreements. LPA reviewed random staff files and observed for the staff to have obtained criminal record clearance and to be associated to the facility. The staff files reviewed were observed to possess valid CPR certification, and training that is completed online and in person. In addition the Executive Director Mariano was observed to possess a valid administrator's certification that expires on 12/09/25. During today's visit LPA gave a reminder of the amount for the facility annual fees, that are due on or before 06/30/25, and provided PIN 809985, should the licensee wish to pay electronically. Based on today's inspection no citations were issued. An exit interview was conducted and a copy of this report and the LIC811-confidential names list was reviewed and provided to Mariano "Quinn" Hernandez, Executive Director.