Routine inspection·July 25, 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 Associate Executive Director (AED) Donnie Johnson. The facility's license shows a maximum capacity of 220 non-ambulatory residents, of which 100 may be bedridden. All rooms are approved for bedridden and the facility is approved for delayed egress on floors 2, 3, 4, and 5. Additionally the facility has an approved hospice waiver for 20. During today’s inspection there were 171 residents in care. LPA, accompanied by AED Johnson and Building Manager John Miller, toured the interior and exterior of the facility and inspected common areas as well as a sample of occupied and unoccupied resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms inspected 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 sinks tested on floors 4, 5, 8, 11, 14, 15, and 16 temped at 106.6, 105.2, 105, 105, 108.6, 105.2, and 106.5F, respectively. 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 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. Kitchen staff demonstrated precautions taken for dietary restrictions. Cooking, dining equipment, and utensils were present. Knives were stored in areas inaccessible to residents. [Continued on LIC 809-C] [Continued from LIC 809] No toxic chemicals or poisons were accessible to clients. Laundry areas were noted to be locked or if they were in use and doors opened, staff were present to monitor. Medications were labeled, as required, and stored in locked areas. Med room staff demonstrated to LPA medication administration procedures and LPA also observed med room staff pass medications to residents. A pool exists on the premises. LPA observed the pool to have a surrounding gate per regulation and gates noted to be secured. Per interview with AED Johnson and Building Manager Miller, only staff have keys to the gates and residents who check out keys are monitored by staff while in the pool area. Per AED Johnson, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, fire sprinkler system, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. Most recent emergency drill conducted with staff was held on 6/26/25 for the topics of earthquakes and fires. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA observed residents engaged in facility led activities, particularly in the Connections for Living and Memory Care units. Various calendars and postings throughout common areas of the facility noted various scheduled activities and events. LPA observed various staff and resident interactions throughout their visit and noted residents to be attended to quickly and treated with respect. LPA interviewed 2 staff and 2 clients, 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. LPA did provide a Technical Assistance for best practices on ensuring 1st Aid/CPR Certificates were current and valid. No deficiencies were cited during the inspection. An exit interview was conducted with Associate Executive Director Johnson to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.