Routine inspection·January 22, 2025

Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director LaTressa Downing and Director of Nursing Divina Salina. According to the facility’s license, the facility has a maximum capacity of 200 residents, of whom 80 may be non-ambulatory on entire second floor. This facility is approved for locked dementia unit with delayed egress doors. Hospice waiver is approved for 12 residents. During today’s inspection, there were 112 residents in care. LPA, accompanied by Divina Salina, toured the interior and exterior of the facility. Pathways were free of obstruction and slip hazards. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Hot water temperature at taps accessible to clients were all compliant. There was at least 2 days supply of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters observed available to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water were observed on the premises. Per LaTressa Downing, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. Required licensing postings were observed in visible areas of the facility. Confidential records were stored in locked areas. LaTressa Downing also presented proof of current/active business liability insurance. An exit interview was conducted with LaTressa Downing and Divina Salina. A copy of this report and Licensee Appeal Rights (LIC 9058 01/16) were provided to LaTressa Downing and Divina Salina