Routine inspection·February 26, 2025

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the above-named facility. Upon arrival, LPA was greeted by Yesenia Leon, LVN, Resident Services Director. LPA explained the purpose of the visit. At the time of arrival, there were nine (9) various staff members and twenty-six (26) residents in care. Entrance interview conducted. The facility is a one-story Residential Care Facility for the Elderly (RCFE) licensed for 43 non-ambulatory of which five (5) can be bedridden. The facility is home to residents with a dementia diagnosis. The facility has a hospice waiver for twenty (20) residents. Currently, there are twelve (12) residents on hospice and one bedridden resident. A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors, and floor coverings were checked. The facility was seen to be in good repair inside and outside. There are four fire extinguishers, inspection was current as of 6/27/2024. The carbon monoxide alarm and smoke alarms are hard wired and in good working order. Additionally, the facility has three pull fire alarms. The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Snacks and beverages are readily available for Residents. Frozen foods are properly wrapped and stored appropriately. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. Medications, First Aid kit, and additional first aid supplies are kept in a locked centrally stored cabinet. First aid kits were observed to be complete. Residents participate independently in holiday and birthday celebrations, current event discussions, live entertainment, local volunteer group participation, Cycling Without Age, local university and community college activities, physical exercise and activities, and outings to parks, restaurants, and other local attractions. Please continue to 809-C, Pg 2. The front entry consists of a sidewalk and concrete ramp entering the facility into the reception area. The facility consists of two wings and an additional building for resident occupancy adjacent from the main building. The main building is a horseshoe shaped building with approximately eighteen residents’ rooms. The adjacent building has seven resident rooms. There is a combination of residents’ rooms with shared bathrooms and residents’ rooms with private bathrooms in the main building and there are only shared bathrooms in the adjacent building. All bathrooms were inspected with secure grab bars and non-skid flooring. The back patio area consists of a garden patio with tables with umbrellas, chairs, and shady trees with a mural wall along the backside. The garden patio is conducive for outdoor visiting as well as various activities and celebrations. There are three dining areas and two common areas available to residents and visitors for dining, activities, and visiting with 24-hour access. The facility maintains a comfortable temperature. Residents’ files were reviewed. LPA noted that on file for each resident was the following: Physician’s Reports, Admission Agreements, Medical Assessments, Identification and Emergency information, Appraisals/Needs Service Plan, and Medication Administration Records (MARs). Medications are administered per Physician’s orders. All persons associated with the facility have criminal record clearance. Administrator certificate is valid. Staff files reviewed had criminal record statements, health screenings, current first aid certificates, and all required training. Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.