Routine inspection·June 28, 2023

Licensing Program Analysts (LPAs) Kevin Mknelly and Jaynae Boyles arrived at the facility unannounced on 6/28/23 to conduct a Required-1 Year Inspection utilizing CARE inspection tool. LPA met with the Executive Director and explained the purpose of the visit. LPA toured the interior of the facility together with Executive Director and maintenance director to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms as well as the rest of the physical plant. In the areas toured no immediate health, safety, or personal rights violations were observed. The residence was found to be clean, safe, sanitary and in good condition. Water temperature logs were checked and water maintained in required range. Facility has required food supplies. There are appropriate staff present to meet the needs of residents. The licensee was found to have two (2) residents who are non-ambulatory residing on the third floor in violation of the fire clearance. LPA reviewed resident files and staff files. 7 Resident files reviewed are complete and current. 7 Staff files reviewed were complete- training is ongoing. LPA requested licensee submit a copy of liability insurance. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.Report reviewed with Kimberly Hagen . Copy of this report and appeal rights provided .