Routine inspection·July 25, 2025

On 7/25/2025 at approximately 9:30AM, Licensing Program Analyst (LPA) Ali Deniz conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. LPA was greeted by Administrator, Tedra Godfrey. The facility is a two-story building licensed for 169 non-ambulatory and 30 bedridden residents, along with a hospice waiver capacity of 20. The facility currently provides care for 148 residents, 7 of which are receiving hospice services and a dedicated memory care unit. Annual fees are current. Required postings were observed. LPA continued with a tour of the facility with Administrator, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers found throughout the facility were found to be last charged on 06/02/2025 at the time of visit. Both smoke detectors and carbon monoxide detectors throughout the facility were interconnected and inspected by an outside agency with current certification dated 10/25/2024. Elevators were found to have current inspection certification with the date of 05/22/2025. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with food delivered twice per week. Food stored in the kitchen was properly stored as per regulations on this day at the time of the visit. Facility closely monitors resident diets with appropriate dietary restrictions posted on kitchen walls. Toxins are stored in designated facility storage closets located throughout the facility. There was a supply of hygiene products and paper products available for residents. All residents’ apartments have lighting & appropriate furnishings. Water was measured at faucets in several residents’ private bedrooms and measured between 113.1- and 115.3-degrees F which is within regulation between 105- and 120-degrees F at faucets accessible to residents. Continued on LIC809-C… Continued from LIC809… Medications located in medication rooms in both assisted living and memory care unit were found to be secured. LPA conducted a spot check of medications and found all administering and records to be in order. Medication management staff also conduct full medication record audits once per month. During the tour, residents observed interacting with staff in common spaces, watching television in their private bedrooms, participating in various activities with Activities Director and mingling in the dining hall with family and amongst each other. Residents are visited by family frequently and interact with one another in the dining area, common spaces as well as in resident private apartments. There is an ample amount of outdoor space and seating for residents on the front corridor and center patio for additional leisure. The facility conducts emergency disaster drills on a monthly, quarterly and annual basis all of which focus on various emergency types and include both staff and residents. Last monthly fire drill conducted on 07/11/2025 At approximately 12:45PM, LPA reviewed 10 resident records and found 10 of out 10 residents have current care plans, signed admission agreements, and physician's report on file. Medication records are thorough and contain physician's orders for each resident. LPA reviewed 6 staff records. 2 out of 6 records did contain documentation of completed training records as required, evidence of first aid training was current. Administrator stated the other 2 out of 6 staff are not working now and they won’t come back to work until they complete their training hours. 1 out of 6 staff have missed training ours. The administrator stated that when the management company changed three months ago the management company took all the staff and residents records with them. The facility is working on maintaining all the needed documents back again. (Technical Violation Issued). 1 out of 6 staff are working in the maintenance department and not required to have a first aid certificate per regulation. LPA reviewed the facility emergency disaster plan. Facility has supplies enough to operate for more than 72 hours in an emergency. Administrator, Tedra Richardson-Godfrey, Administrator Certification 7004281740 is valid through 10/21/2026. Updated copies of the following documents were requested for the facility file and are to be submitted to CCL by due date of 08/05/2025: LIC 308 Designated LIC 500 Personnel Summary LIC 9020 Register of Facility Client’s/Resident’s Copy/Proof of Updated Certificate of Liability Insurance No deficiencies were observed in the areas inspected, No citations were issued during today’s visit.