Facility Evaluation Report

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management / Non-Compliance visit today. The purpose of today’s visit was to ensure the facility was maintaining substantial compliance as outlined in the Stipulation and Waiver; and Order. The order is effective February 25, 2022 – February 24, 2025. The LPA met with Terri Weitzman and explained the reason for the visit. The last legal/non-compliance visit was conducted on 05/22/2023.

The LPA and Executive Director toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations.

There were no obstructions and/or tripping hazards throughout the facility. The facility maintains a comfortable temperature. Fire extinguishers were charged and last serviced within the past twelve (12) months. Planned activities are offered. Activity rooms and common spaces appeared clean and in good repair. The facility has several enclosed courtyards with appropriate outdoor seating for resident use. The swimming pool on the premises was observed to be locked.

RESIDENT ROOMS: The LPA and Executive Director observed eight (8) rooms, and rooms were furnished with clean linens, furnishings and lighting. Restrooms were observed with properly installed grab-bars in resident bathrooms and non-skid strips in shower tubs. At 12:34 p.m., the LPA observed a basket of personal care items and razors in Room 53. At 12:40 p.m., personal care items were in Room 67. At 12:47 p.m., personal care items were observed in Room 17.

FILES: From 12:45 p.m. – 1:10 p.m., the LPA reviewed the files of the three (3) resident that had personal care and hygiene items accessible in their rooms. Out of the three (3) files reviewed, the LPA reviewed physician’s reports and identified that there was one (1) resident (Resident #1 – R1) that was deemed at risk if they have access to personal care items. All three residents had a diagnosis of Dementia.