Facility Evaluation Report

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with staff James Lee and Administrator (AD) Michelle Song and discussed the purpose of the inspection. LPA reviewed Infection Control requirements. At about 7:45AM, LPA and staff James Lee conducted a preliminary inspection of the facility. At about 1:30PM, LPA, AD, and staff James Lee conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication room and observed the following: Structure: this is a large commercial facility. Facility is a 170-bedroom, 180-bathroom, 3 story building. There is 1 large patio with patio covers for the residents. Resident Bedrooms: the 19 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 19 resident bedrooms inspected. LPA tested the call button in multiple resident rooms in assisted living and memory care and noted prompt staff responses. LPA tested the delayed egress system in the first floor memory care and observed it to be functioning properly. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 105 degrees and 122 degrees F, before corrections, in the 12 resident bathrooms inspected. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the storage rooms. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees have not been paid but are not yet due. At about 9:00AM, LPA reviewed 10 resident files and 10 staff files, interviewed 6 residents and 5 staff, and inspected medications for 10 residents. Facility does not handle resident money.