Routine inspection·January 9, 2023

On 1/9/22 at approximately 10:20am, Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met with Executive Director Lizette Guerrero and explained the purpose of today's visit. The structure is 3 story building that accommodates both independent and assisted living. This annual visit focuses on the assisted living community. LPA Jensen toured the facility including the grounds and interior. The community is gated and access is controlled. There is a large green space for activities and benches throughout. There is a centrally located pond on the grounds which is also gated and was observed to be locked. LPA Jensen toured the inside of the inside of the facility including but not limited entrance hall, resident rooms, offices, medication room, activities room, dining hall, kitchen, laundry room and movie room. The facility was observed to have all required signs posted including but not limited to contact information for the Long Term Care Ombudsman, Resident Personal Rights, Resident Council, Family Council, See Something-Say Something and Employee Rights. The temperature in facility ranged between 72 degrees and 76 degrees which falls within the required range of 68-85 degrees. The facility was observed to be sanitary and free of odor with all furnishings and flooring in good repair. The Ansul system was last serviced in September of 2022 and is in compliance. The fire extinguishers were last serviced in September of 2022 and is in compliance. The facility keeps adequate emergency supplies and first aid supplies on hand. All staff encountered where determined to be fingerprint cleared and associated to the facility. The resident rooms were adequately furnished and contained night stands, dressers, chair and adequate lighting. The water temperature in the resident rooms was measured at 118 degrees which falls within the required regulatory range of 105-120 degrees. There are 3 alert signals installed in each room that are in good working order. Continued on LIC 809C.... Continued from LIC 809... There was extensive activities posted available for the residents including bingo, walking clubs, Friday Happy hour, art classes, puzzles, movie night and a variety of outings. LPA Jensen observed a fitness gym and art auditorium with equipment and furnishings and supplies all in good repair. The laundry room was observed to have a lock and appliances in good working order. LPA Jensen toured the kitchen and observed a two day supply of perishable food and a 7 day supply of non-perishable food. The kitchen was observed to be sanitary. A menu was posted in a prominent location for view by the residents and the offerings were consistent with what was being prepared. The refrigerators were observed to be set a temperature of 36 which falls within the required range for preserving food safety. There was no expired food observed. Chemicals and toxins were observed to be kept locked and away from any food products. The medications were observed to be kept in a separate locked room. The medication room was observed to be organized. There were 2 locked medication carts observed with narcotics being double locked. Narcotic medication for Resident 2 (R2) was counted in the presence of Executive Director Lizette Guerrero and staff 1 and the supply of medication was consistent with the records maintained. LPA Jensen reviewed Medication Administration Records (MARs) for R2 and determined that PRN medication effectiveness is being consistently documented. LPA Jensen reviewed 3 resident files and determined them to be in compliance. The facility was found to be in substantial compliance and no deficiencies are being issued as a result of this annual visit. An exit interview was conducted and a copy of this report was given.