Facility Evaluation Report

At approximately 10:15AM, Licensing Program Analysts (LPAs) Felias and Rummonds arrived unannounced to conduct a 1 Year Required Visit, and met with Executive Director/Administrator, Shannon Brown. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Upon arrival, LPAs were informed that there were 34 residents in Assisted Living and Memory Care with 37 Independent Living residents for a total of 71 residents in care. LPAs were also informed that there were 21 staff members on-site.

At approximately 10:30AM, LPAs reviewed the Facility's Staff Roster with Administrator and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 11:00AM, LPAs conducted a walk-though of the facility with Administrator and observed the following: Facility consists of multiple buildings for Assisted Living and Memory Care. Facility has an Extended Care unit which is a separate wing for Older Adults that require a higher level of care. Facility also has independent living units on the property. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a infection control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Hot water temperatures for a sample size of 8 sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit.

Facility's fire extinguishers were last inspected January 2023. Facility smoke detectors are hard wired and connect directly to the local fire station. Facility's smoke and carbon monoxide detectors and sprinkler system were last inspected November 2022 and January 2023. Facility's last fire drill was conducted on July 2023.

At approximately 12:45PM, LPAs reviewed a sample size of 3 resident files. Resident Files were all found to be well organized, thorough and contained the required documentation.