Routine inspection·March 20, 2025

At 8:25am on 03/20/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced to the facility to conducted the annual facility inspection. LPA met with backup Administrator Karla Sanchez, announced who he was and the reason for the visit. LPA noted that the facility is one of four facilities on approximately 2 acres that is gated and there is a recreation building and expansive open courtyard with shaded areas for residents and visitors. During todays inspection, LPA conducted the annual inspection of the facility listed above. Backup Administrator and LPA conducted a full facility tour. LPA noted the facility has 6 bedrooms and 7.5 bathrooms. The bedrooms are single occupancy each with a full private bathroom. The facility has a great room consisting of a living room, dining room and kitchen. There is a designated salon room with full bathroom for the residents of this facility and other 3 facilities on the property. There is a public use half bathroom at the facility entry. The medications are stored in a locked medication cart in the facility hallway. There are combo smoke/carbon monoxide detectors throughout the facility that are hardwired with backup battery. Apex Fire and Safety conducted a successful annual compression test for the fire sprinkler system on 12/03/2024. LPA noted that the facility is clean and in good repair with no obstructions in hallways, doorways or exits. LPA observed fire extinguishers that were tagged current and in the green compression range serviced on 12/03/2024. LPA conducted a sample medication audit and reviewed the facilities Centrally Stored Medication Records (CSMR) and found no violations. LPA noted fresh fruit and snacks in the kitchen for residents to enjoy freely. LPA noted that all resident meals are prepared and cooked in this facility in a separate kitchen located through a door next to the salon and delivered to each facility by hand. LPA observed at least two days of perishable foods and seven days of non-perishable on hand for this facility. LPA conducted a staff and resident file review. During the staff file review LPA noted 2 of 5 staff files not containing a health screen ing. LPA and backup administrator conducted a review of the annual care tool modules. Exit interview done, annual report, citation, and appeal rights were printed and provided to backup administrator.