Routine inspection (multi-day)·August 26, 2024

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Case Management - Annual Continuation visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Resident Care Director Kristel Johnson. Executive Director Jackie Banks arrived during the visit. LPA was away from the facility for approximately one hour between 12:15pm and 1:15pm. The facility is licensed for a maximum capacity of 165 non-ambulatory residents, 6 of which may be bedridden in identified rooms. The facility has a waiver for 15 hospice residents. During today’s visit, the facility had a census of 103 residents. The Administrator for the facility is Jackie Banks and their certificate was valid and current. During visits on 8/15/2024 and 8/26/2024, LPA toured the facility and inspected a random sampling of resident rooms, private and common bathrooms for resident and staff use, kitchen, common areas, and outside space. No bodies of water were observed on the premises. LPA observed delay egress in the facility's memory care which is approved by the facility's fire clearance. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 105.7, 108.0, 109.9, 114.6 and 115.3 degrees Fahrenheit in a random sampling of resident bathrooms. The facility’s internal temperature was measured at 73 and 74 degrees Fahrenheit in different parts of the facility. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Jackie Banks, 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. Continued on LIC809-C page… 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. The facility refrigerator was kept at 37 degrees Fahrenheit, and the facility freezer was kept at -7 degrees Fahrenheit. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, updated physician’s report and medical assessment, documents regarding safeguarding personal property, and personal rights. LPA spoke with staff and residents present at the facility during the time of the inspection. The Executive Director will submit copies of the LIC500 Personnel Report, LIC610E Disaster Plan, and current liability insurance to the Department within 15 business days. No deficiencies were cited on today’s date. An exit interview was conducted with Executive Director Jackie Banks, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).