Routine inspection·September 23, 2025

On 9/23/2025, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced 1-year required annual visit. LPA was greeted by facility staff and was granted entry. LPA advised Administrator, Austin Irwin, of the purpose of the visit. A tour of the facility was conducted. LPA Flores observed the following during todays visit: The facility is a five story structure with a lock perimeter memory care unit on the first floor. The facility is licensed for (200) two hundred non-ambulatory residents to which (10) ten residents may be bedridden. The facility is currently approved for (15) fifteen hospice waivers. LPA observed the facility to be clean and in good repair. Lighting is sufficient for safety. Laundry is done in the designated laundry room on each floor, as well as the location located in the garage’s parking structure. There is a locked location for storing laundry soap, cleaning supplies and chemicals in the closet in the Housekeeper’s closet. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The facility maintains a current emergency disaster plan is maintained. There are no fireplaces at this facility. There is (1) one indoor pool at the facility which has an enclosed and secured perimeter. There are gates located in the front and back of the building. Resident bedrooms had the required bedding, furniture, seating, and lighting. Bathrooms were equipped with grab bars and slip resistant mats in the shower area. Food prep areas are clean and organized. Food supply meets the requirement of (2) two-day supply of perishable and (7) seven-day supply of non-perishables foods. There are food deliveries that come three days out of the week. (Continue to LIC809C...) (Continuation from LIC809) Facility maintains a sufficient amount of emergency food and water supply. There is a secured location for knives and other sharp items located in the kitchen. LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. The facility is maintained at a comfortable temperature for the residents. Per Administrator, Austin Irwin, there are no firearms and/or ammunition on the premises. LPA conducted records review for (10) ten residents. Resident records included but not limited to identification and emergency information, preplacement appraisals, admission agreement, medical assessment, and TB test results, safeguard for personal property/valuables, and personal rights notification. LPA conducted records review for (5) five staff. Staff records included but not limited to first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. Austin Irwin Administrator’s certificate expiration date is 05/08/2026. During today's visit, LPA did not observe any health and safety concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator, Austin Irwin.