Facility Evaluation Report

At approximately 9:05AM, Licensing Program Analysts (LPAs) Felias and Frank arrived unannounced to continue a Required 1 Year visit and met with Executive Director, Shawn Mooney, and Assisted Living Director, Tess Estilo. 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. Facility has an approved fire clearance for a total capacity of 130 individuals, where 81 individuals can be Non-Ambulatory and 15 can be Bedridden. Facility has an approved hospice waiver for 10 individuals. Upon arrival, LPAs was informed that there were 92 residents in Assisted Living and Memory Care with 23 Independent Living residents for a total of 115 residents in care. LPAs was also informed that there were 34 staff members on-site.

At approximately 9:45AM, LPAs reviewed Facility Staff Roster with Executive Director and Assisted Living Director and found that all staff members on site were background cleared and associated to the facility per regulation. LPAs reviewed resident files and resident medication. Files were all found to be well organized, thorough and contained the required documentation. During medication review, LPAs observed that 2 of 8 resident medications were not documented on the log as required. Review of facility's log indicated that facility understands how to document medications appropriately. Discussion with Executive Director indicated that they are audited by their pharmacy monthly (technical assistance issued, LIC9102, regulation 87465(h)(6)). LPAs also followed up on incident reports that were self-submitted to Community Care Licensing (CCL).

Incident Report 1/SOC341: CCL received an incident report and SOC341 on 03/06/2024. Reports state that on 02/29/2024, Resident 1's (R1) family notified facility management of unusual transactions on their joint financial account. R1's family also reported that $40 were missing from R1's wallet. Facility made all appropriate notifications per regulation.

Incident Report 2: CCL received an incident report on 03/07/2024. Report states that on 02/29/2024, facility medication technician observed that Resident 2 (R2's) prescribed medication was discontinued on their electronic medication authorization record (EMAR) and that facility did not have a copy of the discontinued medication. Report continues to state that facility verified R2's medication list, and R2 received a new order for their medication on 03/01/2024. Facility made all appropriate notifications per regulation.