Follow-up·August 29, 2025

At approximately 8:40 AM Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Case Management inspection and met with Administrator Anne Nakiyuka. The purpose of today's inspection was to confirm that areas of concern with the facility's new Memory Care unit noted during a 3/4/2025 inspection have been addressed/corrected. The areas of concern are: Memory Care unit entrance door located in Memory Care lobby/waiting room to be repaired and delayed egress operational from both sides as well as faulty wire repaired/replaced. Memory Care kitchen faucet to dispense hot water with temperatures measuring within regulation. Memory Care range/oven to have barrier in place making any hot elements inaccessible to residents in care. Memory Care refrigerator lock removed. Bathrooms in Memory Care kitchen to dispense hot water with faucet functionality such that Memory Care residents can use them without difficulty. Each Memory Care resident unit will need a slip-resistant mat, strips, or flooring in all bathtub and shower floors. All slip-resistant mats, strips, or flooring must be in good repair and maintain slip-resistant properties. The three [3] exit areas: The north-facing Dovetail exit door, Building H stairwell exit door, and Building I stairwell exit doors to have a barrier preventing Memory Care residents from accessing non-secured area of the facility. At approximately 9:15 AM LPA toured the Memory Care unit with Administrator Nakiyuka. Continued on 809-C... ...Continued from 809 During today's inspection LPA toured the Memory Care unit and Memory Care apartments I168, I167, H154 and H157. During the inspection LPA observed the following: Memory Care unit entrance door located in Memory Care lobby/waiting room was observed to be fully functional and operational. Memory Care kitchen faucet hot water temperature was observed at 118 degrees Fahrenheit which is within the Title 22 regulations of 105 to 120 degrees Fahrenheit. Memory Care range/oven was observed to be fitted with a fire proof and heat resistant barrier mat specifically designed to be placed on a hot cook top to protect users from residual cook top heat. Memory Care refrigerator lock was removed. Bathrooms in Memory Care kitchen and in the Memory Care apartments noted above were observed to have faucet hot water temperatures within the Title 22 regulations of 105 to 120 degrees Fahrenheit. Memory Care resident apartments were observed to have slip-resistant flooring on all shower floors. All slip-resistant flooring was observed to have slip-resistant properties. The three [3] exit areas: The north-facing Dovetail exit door, Building H stairwell exit door, and Building I stairwell exit doors were observed to have to have a barrier with delayed egress doors to prevent Memory Care residents from accessing non-secured areas of the facility. All doors were tested and observed to be fully functional. The areas of concern noted in the 3/4/2025 inspection have been addressed and corrected. Community Care Licensing has approved the Memory Care unit for resident occupancy. No deficiencies cited during today's visit. Exit interview conducted. Copy of report discussed and provided to Administrator Nakiyuka. Signature on form confirms receipt of documents.