Follow-up·March 6, 2024

Licensing Program Analyst Christi Coppo and Licensing Program Manager, Bertozzi arrived unannounced to conduct a Case Management inspection and met with Administrator, Rosemary Jordan and Nestor Mendez, VP of Operations. Floors 3-4 building I,H,G and Floor 2 of building G have been approved by the local fire department to allow for 222 non-ambulatory residents. This approval does not allow for occupancy for Assisted Living or Memory Care in any capacity. The non-approved restricted areas generally identified as such are first floor buildings I, H, G and 2 nd floor buildings I, H, and the 2 nd floor commercial common kitchen. On-site parking must be adequate for the actual number of occupants’ vehicles. Fire lanes are not to be blocked at any point by residents, staff or construction vehicles. This approval is an extension to the previous STD850 and includes the following units: Floor 2 Northeast wing (G wing): U246, U247, U248, U249, U250, U251, U252, U253 Floor 3 Northeast wing (G wing): U346, U347, U348, U349, U351, U352, U353 Floor 3 North wing (H wing): U355, U356, U357, U358, U359, U360, U361, U362, U363, U364, U365 Floor 3 Northwest wing (I wing): U357, U365, U366, U367, U368, U369, U370, U371, U372, U373, U374, RES ST 375, Guest 378, Floor 4 North wing (H wing): U455, U456, U457, U458, U459, U460, U461, U462, U463, U464, U465 Floor 4 Northwest wing (I wing): U457, U465, U466, U467, U468, U469, U470, U471, U472, U473, U474, Guest 478 Continued on LIC809C... Continued from LIC809... LPA initiated a tour of the areas identified in Phase 3A around 9:15am and observed the following: Areas identified as needing final TCO and fire clearance have been completed. LPA confirmed through observation that the water temperature in sinks accessible to residents in care measured at 115.8, 115.6, 119.4 and 120.8 degrees F which is just outside the the allowable range of 105 to 120 degrees F. LPA discussed with VP of Operations turning the water heater down just slightly to mitigate occurrence of temperature breaking the threshold of 105 to 120 degrees F, as required per regulation. LPA and Administrator discussed the importance of maintaining safety while area is still under partial construction. Prior to Assisted Living and Memory Care being approved, Administrator must provide a written plan indicating how potential areas of risk including but not limited to fountains, bioswales, heaters, car garage and compacter will remain safe for residents in care. LPA will update capacity to allow for 222 independent residents on the aforementioned floors and unit numbers. No deficiencies cited during this visit.