Routine inspection·December 18, 2023

Licensing Program Analysts (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility by Director of Safety and Risk Management Glenn Thomas after identifying herself and stating the purpose of the inspection. Facility Profile: Facility will serve elderly residents ages 60 and above; 332 Ambulatory; 340 Non-Ambulatory, of which 6 may be bedridden on the first and second floors in any area except villas. Villas approved for Ambulatory only. Non-Ambulatory approved for all areas except villas. Hospice Waiver approved for 6. Facility has a gated safety security kiosk to allow entry to the community. LPA was accompanied by Executive Director Kline and Director of Safety and Risk Management Thomas during a tour of the facility. A tour of the facility was conducted which included a sample of resident units, the dining area, recreation rooms, and food storage areas. There are multiple building on site as well as villas. Signal systems are in place and operational. PPE supplies are on site. Passageways were free from obstructions. Facility does not feature delayed egress doors or a locked perimeter. Each resident had clean and sufficient bed linens. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars and Non-skid pads. Hot water temperature in accessible to clients were compliant. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were in working order. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA observed several different types of activities, some led by an activities coordinator and some were client based gatherings. Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closed room not assessable to residents. Centrally stored medications were properly stored and locked in cabinets. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions. Staff records review verified that all staff records were complete and compliant. Resident records were reviewed and confirmed compliant. LPA reviewed the theft and loss policy and procedures. LPA conducted a review of In-service training procedures. Transportation procedures are compliant. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. An exit interview was conducted with Executive Director Kline, to whom copies of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. Their signature on this form acknowledges receipt and a copy of the report was given to Executive Director Kline.