Routine inspection·December 30, 2024

Licensing Program Analyst (LPA) Alviso conducted a Required - 1 Year visit, on 12/30/24 at approximately 2:25pm, and met with Administrator Stacy Vermeulen. Hospice care waiver approved for six (6) residents. Facility has a required infection control plan, and a required emergency disaster plan. Fire clearance approval is for one hundred and twelve (112) non-ambulatory residents. The facility consists of two floors, and provides assisted living services to residents as needed. LPA reviewed six (6) resident records. All records were complete. The LPA reviewed six (6) staff records. All staff have criminal record clearance as required by regulation. LPA reviewed staff training records. All staff had required training. Staff have First Aid and CPR certification as required. Facility holds required emergency disaster drills on a monthly basis, ensuring all staff participate in the evacuation drill; Requirement is that emergency drills are held quarterly, an evacuation drill, and three other drills. Drills must be held for every shift. Administrator stated their understanding of meeting the requirement. LPA toured the facility with the Administrator All exits were free and clear of any obstructions. Fire extinguishers were serviced and tagged as required. All five (5) stairwells had the required evacuation chairs. There is also an evacuation chair stored that can be used for the main staircase that leads downstairs to the first floor. The hot water was checked at 110.0 degrees Fahrenheit and 116.2 degrees Fahrenheit which is within regulation. The facility had a sufficient supply of food, perishable and non-perishable. LPA discussed food regulation requirements, with lead kitchen staff and the Administrator, regarding food storage, to ensure no contamination of food supplies. The facility had sufficient supplies of cleaners/disinfectants, paper products, emergency 72-hour shelter in place supplies, emergency water supplies, and sufficient supply of personal protective equipment (PPE). Facility had sufficient lighting in all inspected hallways, bathrooms, and common areas. Facility was at a comfortable temperature during the inspection. All medications were locked up/centrally stored and inaccessible to residents in care. All cleaners/disinfectants/toxins were locked up and inaccessible to residents in care. Administrator has completed the annual updated forms, and will scan them to the licensing office email address. No deficiencies cited during today's inspection. Exit interview conducted with Administrator Stacy Vermeulen.