Post-licensing visit·June 24, 2022

Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a Post-Licensing Inspection. Listed administrator is no longer with the facility. LPA met with Regional Memory Care Specialist, Tammy Kirby. Building and grounds were found to be clean and in good repair. Facility is conducting COVID screening at the front entrance for visitors. LPA was screened by staff. All staff have been vaccinated and boosted. Facility does not currently conducting surveillance testing. Staff were observed wearing masks. LPA and Regional Memory Care Specialist discussed infection control plan. Regional Memory Care Specialist indicated no policy changes regarding visitation and infection control. Facility to submit plan later this month. Personal Protective Equipment is available to support a resident in isolation. Facility will submit documents to change administrator for the facility. Medications are centrally stored and locked making them inaccessible to residents. Toxins are secured and inaccessible to residents. During tour of memory care LPA observed two fire extinguisher behind locked cases. Staff stated that the maintenance coordinator has the key but they do not. LPA is requesting written plan be submitted to Community Care Licensing indicating how facility plans to give fire extinguisher access to memory care staff by July 1, 2022. Exit interview conducted with Regional Memory Care Specialist, Tammy Kirby.