Routine inspection·October 10, 2025

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the above-named facility. LPA was greeted by Administrator Alejandra Nunez. LPA explained the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) and is home to fifty-eight (58) non-ambulatory residents with a Dementia diagnosis, a Hospice Waiver for twenty-five (25) residents, and is approved for delayed egress. Currently, there are nine (9) residents on hospice. At the time of arrival, there were 58 residents in care with three (3) medication technicians/caregivers on duty along with eight (8) caregivers, one (1) Clinical Director, three (3) activities coordinators, and one (1) interim activity director. Administrator and Licensees participated in the inspection. Entrance interview conducted: A tour of the physical environment and accommodations were assessed. The following was noted: LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the facility for fire safety, personal accommodations, and food service. The facility maintains a comfortable room temperature. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. There are approximately sixteen (16) fire extinguishers on the premises serviced once each month since 10/8/2025. There are approximately eight (8) fire pull alarms throughout the facility. There are approximately seventy-eight (78) dual carbon monoxide detectors/smoke alarms throughout the facility. The local fire department is alerted when/if the smoke alarms/carbon monoxide detectors are activated. Fire drills and disaster drills are conducted quarterly. Please continue to 809-C, Pg 2. Residents participate at will in activities such as music and live entertainment, spiritual and religious activities, outings with family members, games, art activities, painting activities, storytelling, word games, travel shows, tri-shaw rides, van rides, and picnics to local parks and attractions. Additionally, the facility participates in the state-based Vitality program through the local community college. Activities are scheduled in the mornings, afternoons, and evenings. Evening activities such as games and storytelling have been incorporated for all residents especially those who may experience sundowning behaviors. The facility incorporated the “Freedom Nature Trax” which is a ‘skid steer’ mobility device that the individual’s wheelchair attaches to giving them the mobility to access trails, parks, beaches, and other outdoor paths with full and/or partial independence. Snacks and beverages are available for residents in care upon request. LPA observed the kitchen area and dining areas to be clean. Cleaning agents and the toxic chemicals are kept in locked supply rooms throughout the facility. The facility consists of four neighborhoods each conducive to the level of care required for the residents. All bedrooms have sufficient lighting, nightstands, beds, and bed furnishings. A locked medication cart is designated for each neighborhood in the Wellness Clinic. First aid supplies are also kept in the Wellness Clinic. Neighborhood #4 is a neighborhood for residents who require a higher level of care. The facility maintains a higher staff ratio in Neighborhood #4 to meet the needs of the residents. Throughout the neighborhoods, there are dining rooms, libraries, beauty salon, social seating areas, outdoor patios, and paved walkways conducive for leisure walks throughout the facility. Due to time restraints, LPA will return at a later date to continue the inspection. Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.