Facility Evaluation Report

Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 10:45 a.m. Upon arrival, the LPA met with Operation Specialist Diane Lugar and the reason for the visit was explained. Entrance interview conducted. Executive Director Jeff Labelle joined mid visit.

At 11:35 a.m., the LPA along with the Operation Specialist 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 noted:

KITCHEN: The LPA inspected the Memory Care kitchen/food service area and the Assisted Living kitchen/food area. Knives and sharps were stored and inaccessible at the time of the visit. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. At 1:04 p.m the hot water in the Kitchen of Assisted Living measured at 129.9 degrees Fahrenheit, and the LPA did not observed the required sign.

COMMON AREAS: At the time of the visit, furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. The fire extinguishers were fully charged and were last serviced 05/08/2024 and 05/22/2024. The LPA observed required postings throughout the common space. The LPA observed the stairwells and they each had an emergency evacuation chair. Activity Rooms were observed and clean at the time of visit. Fireplaces were observed adequately screened. The LPA observed an adequate supply of emergency food and water.

BEDROOMS: The LPA observed eleven (11) randomly selected resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPA observed a sufficient supply of towels and linens. Resident’s cords were tested, LPA observed staff arrive in a timely manner. At 12:31 p.m. the LPA observed the smoke detector in the living room of resident room #274 (AL) inoperable and at 1:30 p.m. the LPA did not observed a smoke detector in resident room #103 in memory care. (Report Continued on LIC 809...)