Non-compliance follow-up·August 12, 2025

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced case management – legal/non-compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance. LPA met with staff and explained the reason for the visit. Executive Director Madison Lewis arrived shortly after. LPA focused today’s visit on ensuring there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. At approx 10:40am LPA conducted a walk through of the facility. LPA observed multiple residents participating in an activity in the activities room. The furniture in the common areas were observed to be clean and in good condition. The facility maintained a comfortable temperature. LPA observed required postings throughout the common space.  Stairwells were observed to have emergency evacuation chairs.  There were no obstructions and/or tripping hazards throughout the facility. Emergency exiting plans/sketch are posted throughout the facility. LPA observed randomly selected  resident bedrooms in assisted living as well as memory care. All resident bedrooms were furnished appropriately and had sufficient lighting.  All resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels.  The hot water temperature was measured  between 105 - 120 degrees Fahrenheit. No obstructions or hazards were observed inside or out. At approx 11:00am, LPA conducted medication review. There are two medication rooms. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRNs have physicians order on file.  Medication appeared to be given as prescribed at the time of the visit. At approx 11:45am, Five (5) resident files were reviewed for, but not limited to, the following: current medical assessments with TB results and current needs and services plan. All records were observed to be in order at this time. No immediate health and safety concerns observed during the visit. Exit interview conducted and report issued.