Facility Evaluation Report

On 4/2/2025 at 11:05AM, Licensing Program Analysts (LPAs) G. Luk and Y. Brown arrived unannounced to conduct a Required - 1 Year inspection. LPAs met with Executive Director, Joan Newman and explained the purpose of the visit.

LPAs toured the facility with Joan including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor area. Centrally stored medications were locked in different carts located in the med room. First Aid kit is complete. The facility has a written emergency disaster plan. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detectors were observed. Fire extinguishers were observed to be full and last serviced on 6/27/2024. Weekly and daily menus were posted in dining areas. Facility is a memory care facility with the exit doors equipped with delayed egress in operating condition.

One week supply of nonperishable and 2-day supply of perishable foods were available. Facility orders food twice a week. Freezer’s temperature was registered at -1 degree F while the refrigerator’s temperature was recorded at 39 degrees F. Hot water temperature was measured at 108 degrees F in a resident's bathroom. Grab bars for each toilet and shower were installed. Non-skid mats/materials were observed. There were adequate lights in each room. Indoor and outdoor passages were free of obstruction. LPA reviewed 5 resident records and 5 staff records starting at 12:00PM. LPA reviewed a sample of resident's medications during inspection.

No deficiencies are being cited on this date.

Exit interview conducted with Joan Newman and a copy of this report provided.