Routine inspection (multi-day)·April 25, 2025

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced case management to complete the annual inspection from 4/17/2025. LPA was greeted by, identified herself to, and explained the purpose of the visit with Executive Director Sheryl Johnston. The facility is licensed for a maximum capacity of 123 non-ambulatory residents, 10 of which may be bedridden. The facility has a waiver for 20 hospice residents. During today’s visit, the facility had a census of 108 residents. The Administrator for the facility is Sheryl Johnston and their certificate was valid and current. During visits on 4/17/2025 and 4/25/2025, LPA toured the facility and inspected a random sampling of resident rooms, private and common bathrooms, facility kitchen, common areas, and outside space. No bodies of water were observed on the premises. LPA observed delayed egress in the facility's memory care. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured within requirements across a random sampling of resident rooms and common bathrooms. The facility’s internal temperature was measured at 74, 75, and 76 degrees Fahrenheit across the facility. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Sheryl Johnston, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and labelled. LPA observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. Continued on LIC809-C page… The facility refrigerator was kept at 40 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate. LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, initial medical assessment, updated annual reappraisal, documents regarding safeguarding personal property and personal rights. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. No deficiencies were cited on today’s date. An exit interview was conducted with Executive Director Sheryl Johnston, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).