Facility Evaluation Report

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrators (AD) Lea Wine and Christine Chon and discussed the purpose of the visit.

The facility is a three story building with resident rooms on each floor, a memory care unit on the first floor, dining rooms, kitchen, laundry rooms, activity rooms, staff offices and outdoor seating areas. The facility appears clean, safe and sanitary. LPA observed all resident rooms to have the required components and furnishings. LPA observed the resident bathrooms to have paper towels, toilet paper and textured shower flooring. LPA tested the water in resident rooms on all three floors to be between 111.7-117.8 degrees Fahrenheit. LPA observed the kitchen to be clean and free of vermin. LPA observed the walk-in fridge and freezer to be at regulatory temperatures to maintain food quality. LPA observed a two day perishable and seven day non perishable food supply on hand. LPA observed the kitchen to have a lock when not in use making the knives inaccessible to residents in care. LPA and AD tested the delayed egress in the memory care unit and it was found to be operational. LPA and AD tested the signal system and had a 2 minute response while in the memory care unit as well as the assisted living side of the facility. LPA observed the memory care dining room to be free of any sharps. LPA observed the toxins and chemicals to be locked in a closet in the kitchen as well as a housekeeping closet on the 3 rd floor and made inaccessible to residents in care. LPA observed a clean supply of linens in the laundry room on the 2 nd floor for resident use. LPA observed the centrally stored medication to be in the wellness office located on the first floor locked in cabinets and medication carts and made inaccessible to residents in care. LPA observed a completed first aid kit in the medication room with all the required components.