Routine inspection·May 7, 2025

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Front Desk Staff Ahdiyeh Dargahi. Executive Director Denise Notter arrived later during the visit. The facility's license shows a maximum capacity of sixty (60) residents, fifteen (15) of which may be bedridden. The facility is approved for delayed egress and secured perimeter, and additionally has a hospice waiver for twenty (20). During today’s inspection there were forty-nine (49) residents in care. LPA and Executive Director Notter toured the interior and exterior of the facility and inspected a number of resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: Bathroom sink in one resident unit was 108F. Extra linens and hygiene supplies were present, as well as multiple stores of Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. Knives were locked and inaccessible to residents. [Continued on LIC 809-C] [Continued from LIC 809] No toxic chemicals or poisons were accessible to clients.  Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Executive Director Notter, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kit was complete and readily accessible. Most recent emergency drill was conducted on 1/26/25. Required licensing postings were observed in visible areas of the facility. LPA interviewed one (1) staff and one (2) residents, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Executive Director Notter to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.