Routine inspection·July 29, 2025

Licensing Program Analyst (LPA) Cuadra conducted an unannounced annual required inspection and met with Executive Director/Administrator William "Bill" Keck and Director of Resident Health Services (RHS), Sharon Shnell-Hobbs. At the front entrance of the facility there is a security guard who screens visitors upon entry; LPA was provided a parking pass and allowed entry onto the grounds. There are currently 25 residents in Assisted Living and 7 in Memory Care. Some residents are receiving hospice services. The facility has an approved hospice waiver for 40 residents. The facility has an approved fire clearance for 679 who may be non-ambulatory, of which two (2) may be bedridden. Approved delayed egress in memory care unit. LPA/RHS toured the buildings and grounds of this 679 bed Continuing Care Retirement Community, kitchen is located in the independent living area (IL), assisted living area (AL: Laurel Place), memory care (MC), Montgomery Center includes a pool, gym and locker rooms. The pool is secured and entry is made with a FOB system. Ten resident's bedrooms were equipped with lighting and furnished per regulation. Storage and Janitor closets were inspected and contained an ample supply cleaners, hygiene and paper products. Toxins were stored in the janitor closet and inaccessible to residents. Housekeeping carts were observed in hallways locked and secured. Food is primarily prepared in the IL kitchen. Food was found to be stored in a safe manner with the amount of fresh and non-perishable foods within regulation. Menu including dietary restrictions were observed. Activity calendar and complete first aid kit was observed. Required postings observed. Continued on 809-C... Continued from LIC809... Fire extinguishers were located throughout the facility and in kitchens with a charge date of January 2025. Facility is equipped with a fire pull system and sprinkler system. Smoke detectors are hard wired. Last certification of fire system was conducted on 7/11/25. Exit doors in the MC unit have a delayed egress which was functional. There are three generators available. Emergency lights and food was available for emergencies. Emergency drills are conducted quarterly on each shift in AL and MC with the last one being completed 6/2025. Evacuation chairs observed at each stairwell. Water temperature measured 112.8, 115.7, 116.8, 117.1, 112.1, 116.3, 115.4 and 117.3 degrees F which is within regulation between 105 and 120 degrees F in faucets used by residents. All resident's bathrooms contained necessary grab bars and non-slip floors/mats. Medications are stored in two medication carts per unit for a total of four medication carts which were locked and secured. LPA reviewed 9 staff and 10 resident's files. 5 out of 9 staff do not have 1st aid/CPR certificates current (technical violation was issued), but they do have required additional training 20 hours complete. Residents have medical assessments and care plans updated. Administrator certificate for administrator Bill Keck #7001996740 expires 8/21/25. Per Administrator, required documentation to renew their certificate has been submitted to the department's certification unit. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility LIC610E- Disaster Plan Evidence of Liability Insurance No deficiencies cited during today's visit. E xit interview conducted with RHS Sharon Shnell-Hobbs and copy of this report was given.