Routine inspection·March 18, 2025

On 03/18/2025 at 10:05AM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to this facility for the required annual inspection. Entry into the facility is unobstructed and LPA met with Executive Director (ED) Marguerite Crockem. The facility is approved for a Hospice Waiver for twenty (20) residents. The facility is approved for delayed egress. LPA and maintenance manager Enrique Serralta toured the exterior of the facility. Physical Plant: The facility is operating within capacity and not beyond the conditions of the license. There are no pools or other bodies of water located on the premises. The facility is being maintained at a comfortable temperature for residents in common areas. Residents are able to set individual temperatures within their unit. All passageways are kept free of obstruction. Hot water temperature was measured in five units at random and all measured within regulatory limits. There are grab bars for each toilet, bathtub and showers used by residents. The facility has an operable signal system that is operable from the memory care unit. Fire safety installations such as extinguishers, sprinklers, and alarms are monitored by an authorized fire inspection outside company and LPA observed proof of inspection completed on 10/24/2024. The commercial kitchen was last inspected by the same third party company on 10/24/2024. Fire extinguishers were observed to be charged. Overall the facility is in good condition; it is clean, sanitary and free of foul odors. Kitchen and Food Service: The total daily diet provided to residents appears to be of the quality and in the quantity necessary to meet resident needs. There is a minimum of one week supply of nonperishable foods and two days of perishable food items. All readily perishable food or beverages capable of micro-organism growth are being stored in covered containers at appropriate temperatures. Commercial refrigerator and freezer are maintained within regulatory temperatures. Kitchen hood was last inspected by the same outside company on 10/24/2024. Medication, Care, and Supervision: The facility has ensured sufficient and competent staff to provide the services needed to meet resident needs. Chemicals and items which may pose a danger are stored inaccessible to residents. LPA Renese Howell-Small inspected medications with charge nurses and found medications in their original containers. Medications appear to be dispensed according to the physician's orders. Resident and Staff Files: LPA reviewed a sample of staff and resident files. Staff files had the required documentation including a health screening report and current first aid and/or CPR certification. Resident files had the required documentation including admission's agreement, consent forms, appraisal and/or needs and services plan, and updated physician's reports. First Aid training are on file for staff who provide direct care and supervision to residents. Staff have training for Dementia care and Activities of Daily Living. Operations and Administration: Disaster Plan is present. Executive Director Marguerite Crockem is present in the facility a sufficient amount of hours and the administrator certification is up to date. The required licensing and ombudsman posters are posted and in public view. Residents rights are posted and a copy is kept in the resident's file. No deficiencies were cited during this visit. An exit interview was conducted where this report LIC809 and LIC809C was discussed and provided to the Executive Director.