Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Ramirez conducted required annual inspection. LPA met with Minerva Naranjo (Director of Health Services), Tanya Madrid (Director of Resident Services) and Susan DeGange (Q&A Coordinator) and discussed the purpose of today’s visit.

This facility is licensed to serve (252) ambulatory residents and (108) non-ambulatory of which (18) may be bedridden. There are eighty-two (82) residents under Assisted Living. There are zero (0) bedridden residents at this time. This facility may retain no more than fifteen (15) hospice residents. There are eleven (11) residents under hospice care. Summer House Dementia Unit II is approved for (5) non-ambulatory residents with secured perimeter, locked gate and locked doors. There are currently twenty-two (22) residents in the Summer House Dementia Unit. The total number of residents at this facility is 212.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected ten (10) rooms; of which five (5) in Summer House Memory Care and five (5) in The Lodge building of the facility. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. Facility maintains a monthly waterlog to record water temperature throughout the facility. LPA Ramirez observe postings encouraging proper hand washing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez tested emergency pull cord in room#119. Staff responded 2 minutes later to assist. LPA Ramirez observed evacuation chairs in stairways.