Pre-licensing visit·May 16, 2025

Licensing Program Analyst (LPA) Teresa Camara conducted a pre-licensing visit to the above noted facility. The LPA met with administrator/executive director (ED) Brandy McCauley, LVN. This facility is currently operating under a different license and this is a change of ownership application. A dementia program was included in the plan of operation. A Hospice Waiver has been requested. At 9:38 a.m. LPA completed the Component III with the ED. The facility is two-story and has one elevator. At 10:15 a.m. a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for 121 non-ambulatory residents and delayed egress is approved for the memory care unit. The facility has ninety (90) private resident bedrooms and fourteen (14) shared rooms. Some shared rooms may be used as private rooms. None of the resident's rooms have direct exits outside. The residents choose to bring their own furniture. LPA inspected eleven (11) resident rooms. All were appropriately furnished with beds, clean linens, nightstands, lamps, chests of drawers, chairs and closet space. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. Rooms were free of odors. Window screens were clean. The rooms were maintained in good repair. (continued on LIC809-C, page 2) (continued from LIC809, page 1) All resident rooms have private bathrooms. The hot water temperature was tested in four (4) resident bathrooms and was found to be within the required range of 105*F and 120*F. There are a total of six restrooms open to the public. All bathrooms were observed to be cleaned and stocked with toilet paper, towels and soap. All bathrooms were equipped with grab bars next to the toilet and in the showers. All showers had non-skid surfaces. There are no sleeping quarters for staff. All three shifts (am, pm, night) have awake staff only. Resident and staff records are stored in medication rooms and business office . Medications are centrally stored in medication carts in the locked medication rooms. The first aid supplies are stored in the medication rooms. The facility has a commercial kitchen which is not accessible to residents. Knives are stored in the kitchen. The supply of dishes, utensils, pots, pans and drinkware is adequate. The walk-in freezer was maintained at -2 degrees Fahrenheit (-2*F), the walk-in refrigerator was maintained at 33 degrees Fahrenheit (33*F) and the other refrigerator was maintained at 37 degrees Fahrenheit (37*F). The supply of perishable and nonperishable food is adequate. A supply of emergency water is kept in a garage. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. No flies or signs of other vermin were observed. The common areas were appropriately furnished, and the lighting was adequate. There are activity rooms and television rooms with comfortable seating in assisted living and memory care. There was sufficient space to accommodate both indoor and outdoor activities. Night lights and emergency lighting were maintained in hallways and passageways to nonprivate bathrooms. There is a screened fireplace located in assisted living adjacent to the large dining room. The delayed egress doors in memory care are tested weekly. The physical plant is consistent with the submitted facility sketch/floor plan. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit. (continued on LIC809-C, page 3) (continued from LIC809-C, page 2) The facility smoke alarm system is hard wired. They have carbon monoxide detectors in common areas. The carbon monoxide detectors are tested by maintenance staff weekly. The fire sprinkler system, smoke alarm and fire doors were last inspected 4/16/2025 by fire marshal approved vendors. Maintenance checks smoke alarms and sprinkler systems monthly and weekly. Fire extinguishers are inspected by maintenance and annually by an approved vendor with the last annual inspection having been completed on 4/10/2025. Emergency evacuation drills are conducted on all shifts monthly. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted. Emergency telephone numbers are posted in the medication room. Other required postings were observed. The exterior passageways were clean and clear of any obstructions. There is a fenced outdoor area with a covered patio for memory care residents. There is a covered patio and outdoor area for assisted living residents. There are no bodies of water on the premises . There is a garage used for storage which remains locked at all times. Maintenance keeps their tools stored in the locked garage. The garage is a stand alone building and not physically connected to the facility. There were no deficiencies observed during this pre-licensing visit. This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating under the new license until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.