Routine inspection·June 4, 2025

Licensing Program Analysts (LPA) Kesha Lewis arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA was met by staff. LPA explained the purpose of the visit to staff. Executive director joined about two (2) hours later. LPA observed the facility to have adequate food supply of 7 days non-perishables and 2 days perishables in place. LPA observed, fire extinguishers inspected on 02/18/2025 and current, smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance. LPA reviewed eight (15) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required. LPA reviewed eight (20) resident facility files of which four (10) for memory care and four (10) were assisted living, COVID-19 Plan, and survey binder. All necessary documents were in place. LPA and administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 110 bed facility with a current census of 105. There is entry door is leading to a common area that leads to the kitchen with a hallway to the bedrooms and bathrooms. Chemicals and medications noted to be locked to residents in care. No bodies of water were observed at the facility. Hot water temperature was measured at 109 F degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. All necessary documents were in place. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils. Elevator inspection is current to 11/19/2025. The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point. Exit interview and copy of the report was given.