Non-compliance follow-up·June 17, 2025

At approximately 8:40 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Legal Non-Compliance Case Management inspection and met with Executive Director (ED) Brandee Rodriguez. LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA was informed that there are twenty-three (23) residents in Assisted Living and seventeen (17) residents in Memory Care for a total of forty (40) residents. As a requirement of the Stipulation and Waiver; and Order dated July 18, 2022, the facility submitted a Monthly Quality Assurance (QA) Audit that includes but is not limited to staffing, physical plant, dementia care, medication records and infection control. LPA reviewed QA and found that there were dirty vents noted. The vents were cleaned and LPA observed no dirty vents during the inspection noted below. At approximately 9:30 AM, LPA conducted a tour of the facility that included both memory care units, the assisted living care unit and grounds. Facility appeared to be safe, sanitary and in good repair. LPA reviewed the most recent staff schedule to verify that facility has sufficient staff for resident's needs including but not limited to residents needing two person assists. The facility staff two caregivers for each unit on each shift, with a rotating Medication Technician (MT) that will serve as the MT for both Memory Care buildings. Managers will provide additional assistance for breaks and lunches, when needed. Meal breaks were observed to be staggered to allow for ample staff coverage. The facility will be holding a job fair on 6/18/2025 to find potential staff members. Continued on 809-C... ...Continued from 809 Facility provides monthly training to staff in order to comply with the Stipulation and Waiver, and Order and contracts with a vendor to ensure the staff training requirement are met. Per QA, check of staff training was in compliance. LPA reviewed three (3) memory care resident files. Three (3) of (3) resident files were observed to be well organized and thorough with all required documentation including current Appraisals/Needs and Services plan. LPA reviewed five (5) staff files. All staff files were found to be with all required documentation including First Aid and CPR certification and proper annual training and stipulation training documentation. No deficiencies cited during today's visit. Exit interview conducted. Copy of report discussed and provided to ED Rodriguez. Signature on form confirms receipt of documents.