Follow-up·May 4, 2026

Licensing Program Manager (LPM) Liza King and Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility to deliver complaint findings. LPA and LPM met with Elvyra Abare whom identified themselves as the newly appointed Executive Director. During todays visit verification of fingerprint and association was conducted to ensure the individual was cleared to be present and working in the facility. Current census 68 in Assisted Living and 28 in Memory Care, 2 residents on hospice throughout the building. For Admin changes, the RO requests the following documentation to be submitted by 05/06/26 · A letter from the licensee and/or Board appointing the individual as the Administrator · LIC308 · Copy of current Admin Cert · Any documentation that meets the education and/or experience requirements, if applicable · LIC 200 signed by the licensee or designee · LIC 500 to indicate the days/hours the administrator is in the facility · LIC 501 so that we can determine if the Admin meets the education/ experience requirement. cont. A tour of the facility was conducted. Residents in the memory care (MC) neighborhood appeared clean and well kept, breakfast service was concluding, then residents were engaged in a sing along followed by exercises. Five rooms were entered, 5/5 rooms contained personal care supplies. 1/5 rooms contained cleaning supplies; tide pods-this rooms door was propped open. Interview with a caregiver deemed the facility does not have a practice in place to determine which residents are allowed access to personal care supplies and which are not. Additionally, cleaning supplies were observed under the sink in an unlocked cabinet. A ladder and tool case with various tools were left unattended. Staff belongings including purses and backpacks were left accessible to residents. These practices present an immediate risk to residents in care. A discussion occurred with the Administrator whom acknowledged the issue. A review of staff training records revealed an inservice had occurred over the past 30days re: accessibility to cleaning solutions and toxins. On the MC patio a long metal rod was observed. A pull cord was pulled in the MC area. After not being addressed for several minutes LPM observed that the volume was muted on t he device which alerts staff a pull cord has been pulled. Review of a second device showed the same volume setting. 4 resident files were reviewed. 1/4 documented the resident was not allowed access to personal supplies, additionally 1/4 documented lack of safety awareness and impulsivity and able to have access which may be contradictory. LPM r ecommends reviewing this documentation throughout the MC area and creating a plan to ensure those that would be at risk are protected and staff are knowledgeable. Diet orders were verified against the resident physician orders and notification to care staff which is posted in a conspicuous place for the staff to refer to with no concerns. Water temp was within regulatory range. No odor was present and the area appeared clean and well-kept, except for the refrigerator which should be wiped down. Recommendation is to establish a cleaning schedule for the communal and private refrigerators throughout the building. Communal bathrooms were clean. Observations were conducted on the Assisted Living (AL) side at lunchtime. Live music was being performed prior to lunch service. Water temp was within regulatory range. Eight rooms were entered and met regulatory requirements. No odor was present and the communal area appeared clean and well-kept, except for two communal refrigerators which should be wiped down. Recommendation is to establish a cleaning schedule for the communal and private refrigerators throughout the building. Communal bathrooms were clean. cont Observation in the kitchen area showed dead carcasses of bugs, guidance was provided in establishing a routine cleaning schedule behind appliances and corners of rooms. Additionally, garbage can lids on the exterior of the building are not being closed which attracts insects and rodents. Additionally, the following documentation was reviewed and are of no concern at this time · Backflow Testing conducted 07/01/2025 · Ansul Semi Annual Inspection 10/17/2025 · Fire Alarm Annual Inspection and Testing 10/17/2025 · Annual Sprinkler Testing 10/17/2025 · Elevator Inspection 10/28/2025 · Disaster Plan inc Earthquake, Relocation, Communication, Pandemic, Power Failure, Active Shooter, Bomb Threats, Infection Control Plan and LIC610. Provided a new Administrator is present it is recommended a review of the above and documentation. The above information is not all inclusive of todays visit, this information and these observations are in addition to those being cited on complaint visit reports dated today. Citations are being issued as a result of these observations and findings and an exit interview was conducted with Elvyra Abare. Appeal rights were provided.