Routine inspection·April 25, 2024

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Interim Executive Director Divinia Nunez. According to the facility’s license, the facility serves 214 residents ages 60 and above, of which 23 are ambulatory and the remaining residents may be non-ambulatory, including 25 bedridden. Delayed egress was approved in building C1. Hospice waiver was approved for 25 residents. During today’s inspection, there were a total of 108 residents in care. This facility does feature a secured perimeter. LPA, accompanied by Divinia, toured the interior and exterior of the facility, and inspected a sample of bedrooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. 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 resident activities. The facility’s ambient internal temperature was 72 F. Hot water temperature at taps accessible to residents were all compliant: Bedroom B105 bathroom sink was 111.9 F, Bedroom B102 bathroom sink was 110.4 F, bedroom A111 bathroom sink was 114.1 F and bedroom C106A bathroom sink was 112.2 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in locked areas. (continued on next page, LIC 809-C) A pool was present at the facility. The pool fence was at least 5 feet high and the fence did not obstruct the pool from view. The gates to enter the pool were self-latching. Per Divinia Nunez, 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. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed multiple staff and residents. LPA reviewed multiple staff and residents records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. Divinia also presented proof of current/active business liability insurance. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Divinia, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit. ***NOTE: LPA left the facility for one hour during the visit.