Routine inspection·June 18, 2025

Licensing Program Analysts (LPAs) Martha Arroyo and Valeria Conway conducted an unannounced annual inspection. Upon arrival, the LPAs met with the Health & Wellness Director, Marjorie Manning and explained the reason for the visit. Entrance interview conducted. Starting at 10:05am, the LPAs along with the Health & Wellness Director, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: RESIDENT ROOMS/RESTROOMS: The LPAs observed five (5) resident rooms in the assisted living side and six (6) resident rooms in memory care. All resident rooms were furnished appropriately, with clean linens and appropriate furnishings. The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 10:20am, the hot water temperature was measured in five (5) assisted living bathrooms and six (6) memory care bathrooms, and the temperature measured within the required range of 105 – 120 degrees Fahrenheit. KITCHEN: Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. The LPAs observed sufficient perishable and non-perishable foods to meet the minimum two-day and seven-day supply of food and water. Refrigerator and food pantry were checked for proper labels and expiration dates and food labels had expiration date clearly marked. An adequate amount of emergency food and water was observed; properly stored. Report Continued on LIC 809C... Report Continued from LIC 809... COMMON AREAS: The LPAs observed common areas to be clean and in good condition. There are games and/or activity supplies in the activity rooms as well as throughout the facility. There was sufficient space to accommodate both indoor and outdoor activities. The facility maintained a comfortable temperature. Required postings were observed throughout the common space. The LPAs observed stairwells 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. Several fire extinguisher are located throughout the facility and were observed to be fully charged and last serviced on 04/18/2025. OUTDOOR SPACE: The LPAs observed the outdoor garden in assisted living and memory care which had shaded seating areas for resident use. All passageways were observed to be clear and free of hazards. RECORD REVIEW: The LPAs reviewed resident and staff records beginning at 12:25pm. Ten resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan. All records were in order. Ten personnel files were reviewed for, but not limited to: personnel records, health assessments with TB results, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All files were complete. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPAs reviewed the facility's infection control policy as well as their emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Daily vehicle inspection list, current registration, and insurance was reviewed for facility vehicle. Report Continued on LIC 809C... Report Continued from LIC 809C... The last fire safety inspection was completed on 10/15/2024 and was found to be in compliance with Fire Code Regulations at the time of inspections. Emergency disaster drills conducted quarterly as per regulation; last disaster drill conducted on 04/18/2025. During today's visit, the LPAs interviewed one staff and two residents. No concerns were noted. MEDICATION REVIEW: The LPAs reviewed medications at approximately 11:25am. Medications are centrally stored in locked medication carts on the 2nd floor and on the 3rd floor. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications are properly documented on the centrally stored medications and destruction record. Medications appear to be given as prescribed. Exit interview conducted. A copy of the report was provided.