Routine inspection·September 18, 2024

On 9/18/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Health Services Manager, Samantha Curro & Assistant Executive Director, Adrienne Fair. The facility currently provides care for 148 residents, 10 of which are receiving hospice services, along with a designated memory care unit. LPA continued with a tour of the facility with staff, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers located on each resident floor, kitchen and common spaces were found to be charged. Smoke and carbon monoxide detectors were present with fire safety Inspection completed in July 2024 indicating all fire safety devices and systems are in order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen, sufficient for residents in care. Food supply is replenished constantly throughout the week and stored properly. Facility provides a wide variety of meal preferences and preparation while also ensuring proper dietary restrictions are followed. Cleaning supplies and other toxins are safely stored in locked closets throughout each floor, and housekeeping carts all of which were secured upon inspection. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items. Residents that were out in the community the inspection were observed interacting with staff, fellow residents and visitors in the common areas, or in their bedrooms resting. The facility encourages regular family visits and utilizes a wide variety of activities with LPA observing staff engaging continuously with residents, offering activities based on individualized preferences and abilities. LPA found that staff and resident engagement is well practiced with activity calendars developed on a monthly basis. Residents are encouraged to participate and showcase in art exhibits and displays for resident engagement. Residents were observed to have a positive and personable relationship with staff and Assistant Executive Director. There is a single outdoor patios for resident use, all equipped with appropriate shading Continued onto LIC809-C LPA conducted a sample file review for residents and found all items to be in order including needs & service plans and physician's reports. Upon a spot check of staff files, LPA found that caregiver staff have current 1st aid and CPR and annual training on track for completion. In addition, newly hired staff were found to have appropriate health screening and tuberculosis results on file. LPA toured facility bus and found observed first aid kit and charged fire extinguisher to be present. Lastly, A spot check of medications including narcotic was conducted and found that all medication counts and records are in order. Adrienne Fair's Administrator Certificate 7008764740 is currently active through 11/26/2025. LPA requested the following documents be sent to CCL by COB 10/2/2024: LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan Liability Insurance No deficiencies cited during today's visit.