Routine inspection·October 11, 2024

On 10/11/2024, Licensing Program Analysts (LPA's) Tobola Jain conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Plant Operations Director, Ping Huang & Executive Director, Cleitus Jones. The facility currently provides care for 136 residents, 12 of which are receiving hospice services, along with multiple designated memory care units. LPA's 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 with last inspection date of 7/15/2024. Smoke and carbon monoxide detectors were present with fire safety Inspection completed 7/3/2024 indicating all fire safety devices and systems are in order. Emergency drills are conducted on a monthly basis with the last drill performed on 9/28/2024. 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. Water at faucets accessible to residents measured between 108.1 degrees F and 114.4 degrees F and within regulation. 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 in activities, well observed in both assisted living and memory care units. Residents were also observed to have a positive and personable relationship with staff and Executive Director. There are multiple patios for resident use, all equipped with appropriate shading Continued onto LIC809-C LPA's conducted a sample file review for residents and found all items including needs & service plans and medical assessments up to date. 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. However, staff (S1) does not have health screening report on file. Technical Violation issued. Lastly, A spot check of medications including narcotic was conducted and found that all medication counts and records are in order. Cleitus Jones's Administrator Certificate 6069222740 is currently active through 4/4/2026. LPA requested the following documents be sent to CCL by COB 10/25/2024: LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan Liability Insurance No deficiencies cited during today's visit.