Facility Evaluation Report

At approximately 10:20AM, Licensing Program Analysts (LPA) Felias arrived unannounced to conduct a 1 Year Required Visit, and met with Executive Director/Administrator, Shannon Brown, and Health and Wellness Nurse, Melanie Fenn. 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, LPA was informed that there were 35 residents in Assisted Living and Memory Care with 28 Independent Living residents for a total of 63 residents in care. LPA was also informed that there were 26 staff members on-site.

At approximately 10:45AM, LPA reviewed the Facility's Staff Roster with Health and Wellness Nurse and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 11:30AM, LPA conducted a walk-though of the facility with Health and Wellness Nurse 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 Assisted Living residents 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 2024. 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 January and August 2024. Facility's last emergency/disaster drill was conducted September 2024.

LPA followed up on incident reports that were self-submitted to Community Care Licensing (CCL).