Routine inspection·April 22, 2025

On 04/22/2025 at 8:30am, Licensing Program Analyst (LPA) Pang Lee and Shakaricka Hughes arrived at the facility to conduct an unannounced annual inspection. LPA Lee and Hughes met with Kathleen Gilbey explained the purpose of the visit. The facility designated administrator was present in the facility. The current census is 146 and facility staff is 112 LPA's inspected the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA's also toured both the assistant living and memory care. LPA's observed activity rooms, wellness cove, private dining, massage room, and media ballroom. LPA's observed sufficient lighting throughout the facility. LPA's observed the facility to be clean and in good repair. LPA observed residents’ rooms and they are equipped with the required furniture. LPA's observed resident room 109 had a very strong urine odor. It was learned R1 moved to the facility of 2/1/2025 and it was learned that resident has a change in condition. Based on record review, resident has proper documentation in place. During today's visit maintenance shampooed resident's carpet. Resident will relocate to another room temporarily. There are no bodies of water present. LPA's toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 109.1 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. Continuation 809-C The fire extinguisher is located in the hallways of each floor and was last serviced on 04/16/2025. LPA's observed the facility has a has a public telephone in the staff offices and the facility has the required posters posted. Facility thermostat was 73 degrees Fahrenheit. LPA's observed toxins located in the kitchen area and kept locked and inaccessible to residents. LPA's observed sharp knives in the kitchen and inaccessible to residents. LPA's checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed 5 residents medications and the medication administration record (MAR) was complete. The first aid kit was checked and contained the required components. LPA's requested resident and staff files for review. LPA's reviewed 10 out of 10 resident files and it was complete.LPA's reviewed staff criminal record clearances, and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared. The following documents will be email to LPA by end of day 5:00 PM: (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (3) LIC 610 Current Emergency Disaster Plan (4) Proof of Current Liability Insurance (5) LIC 500 Current Personnel Report (6) LIC 309 Administrator Organization As a result of this annual visit, the facility is in compliance with Title 22 Regulation, An exit interview was conducted with Kathleen Gilbey and a copy of these LIC 809, LIC 809-C, LIC 9102 reports, and Appeals rights were provided to the facility.