Routine inspection·October 20, 2023

Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived unannounced at the facility to conduct a required 1-year annual inspection. LPAs met with Senior Executive Director (ED), Kim Hagen , and explained the purpose of the visit. Facility is licensed for 325 non-ambulatory residents, hospice waiver of 20. Facility currently has 192 residents, 11 on hospice services. LPAs and ED conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: eleven (11) rooms in Memory Care/ Life Guidance unit, nine (9) rooms in Assisted Living, three (3) laundry rooms, two dining rooms, Salon, Movie Theater, Library, kitchen, mini Grab & Go Grille, Learning Center, Employee Lounge, and the courtyard. LPAs observed the facility to have the mandated posters posted in a conspicuous space. LPAs observed Administrator Certificate for ED to be expired. ED informed LPAs her certificate has been renewed but did not receive the copy. LPAs confirmed on CCLD website, Administrator Certificate #6050074740 is current with expiration date of 12/07/2024. LPAs informed ED LPA Yang will contact Admin Cert unit for a copy of ED's certificate. In areas toured, LPAs did not observed any violation of health, safety and personal rights. LPAs completed the CARE tool and found the facility to be in compliance at this time. No deficiencies observed. Exit interview conducted and a copy of the report was provided.