Routine inspection·February 25, 2025

On 2/25/2025, Licensing Program Analysts (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Regional Operations Specialist, Alan Fox. The facility currently provides care for 164 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, memory care unit and resident common spaces were inspected. Fire Extinguishers located throughout the inspected portions of the building were found to be charged. Smoke and carbon monoxide detectors and fire safety systems are interconnected. Cleaning supplies and other toxins are safely stored in locked closets throughout the facility, and housekeeping/maintenance rooms 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 in the memory care unit that were awake during 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 observed group karaoke and movies presented to residents along with a variety of activity supplies available. LPA found that staff and resident engagement is well practiced with activity calendars developed on a monthly basis. Residents were found to have a positive and personable relationship with staff. Continued onto LIC809-C LPA conducted a sample file review for 10 residents and found all items to be on file. LPA's found that residents Needs & Service Plans and Medical Assessments were up to date. Upon a spot check of 10 staff files, LPA found that caregiver staff have current first aid and annual training, health screenings and TB results on file. Lastly, a spot check of medications was conducted and found that all medication counts and records are in order. LPA will be conducting an annual continuation to further inspect remaining resident living quarters, kitchen and food supply and facility transportation. Executive Director, Fili Igafo's Administrator Certificate 7003332740 is currently pending for renewal but has been received by the department with application received 11/18/2024. LPA requested the following documents be sent to CCL by COB 3/11/2025: LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan Liability Insurance No deficiencies cited during the visit.