Pre-licensing visit·May 9, 2025

Unannounced Prelicensing visit made out to this facility on 05/09/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Edgar Parra, who was briefly interviewed at this time. Current census was 82 residents. It was learned that there were (8) residents under the care of hospice at this time while (12) other residents were receiving services through home health as well. This facility does have a hospice waiver approved for (15) residents and does have a program on file to address dementia care for residents at any given time. It was learned that there weren't any residents deemed to be bedridden at this time. This facility does not have a fire clearance to be able to accept/or retain any residents deemed to be bedridden at this time. A tour of this facility was conducted. Administrator certificate was observed to be present for facility designated Administrator Edgar Parra. The expiration date was set for 07/29/2024. All documents have already been submitted to renew at this time. Kitchen area was toured. Cabinets and drawers were reviewed. Food preparation stations, dishwashing station, and other areas intended for meal preps were toured. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. This LPA did observe additional food storage units which were present and functional at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted. Medication rooms, located on each floor, were reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications were discussed with the facility designated medication technicians at this time. The medication carts were observed to be locked and made inaccessible to the residents at this time. A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. It was learned that there were (3) different floor plans for residents on the Assisted Living portion of this facility. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Linen closet, located in the facility laundry area, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time. A tour of the Memory Care unit, referred to as Expressions, was conducted. Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 08/12/2024 by the local fire extinguisher company, Jorgensen Co., and in compliance at this time. First aid kits were observed to be present and contained all of the required components at this time. Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gates, and exits was conducted. A review of (5) facility resident files was conducted. A review of (5) facility personnel files was conducted. The following deficiencies were observed and will need to be brought into compliance by this facility prior to moving forward with licensure of this facility: Based on facility resident record review, the licensee did not comply with the section cited above in [1] out of [5] resident files did not have an updated medical assessment completed which posed an immediate health, safety or personal rights risk to persons in care. Based on record review, the licensee did not comply with the section cited above in [1] out of [5] facility resident records was missing the determination for ambulatory/non ambulatory status which poses an immediate health, safety or personal rights risk to persons in care. The facility designated Administrator will notify this LPA upon completion of the correction for the above deficiencies. A follow up visit will then be conducted to verify these corrections were made and that this facility is in compliance. Exit Interview