Facility Evaluation Report

Licensing Program Analysts (LPAs) Jeannette Olson and Kristin Kontilis conducted an unannounced on-site one-year Infection Control Inspection visit to the above-named facility. LPA arrived at 12:00 pm and was greeted by Staff 1 (S1). Administrator Peter Bonilla and Interim-Administrator Mark Cortes were present at the time of arrival. There were 59 residents in care in the Assisted Living unit with 1 medication technician and 3 caregivers on duty. In the “Compass Rose” Memory Care unit, there were 21 residents with 1 medication technician, two caregivers, and 1 activities coordinator on duty. The Compass Rose Resident Services Director who currently oversees the Assisted Living and Memory Care units of the facility was also on duty.

A Mitigation Plan has been submitted to CCLD. LPAs explained the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) and is home to non-ambulatory residents with a dementia diagnosis. There are 18 residents currently on hospice.

The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked. The facility was seen to be in good repair inside and outside.

Throughout the facility, there are approximately 10 fire extinguishers and 5 fire pull alarms. The pull fire alarms alert the local fire department when activated. Fire inspection was most recently conducted on 6/17/2022 and 6/21/2022. There are approximately 81 dual carbon monoxide detectors and smoke alarms throughout the facility.

The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Snacks and beverages are readily available for Residents. LPA observed the dining areas are clean. LPA observed kitchen cabinets, refrigerator, stove, and counters are clean.

Medications and First Aid supplies/kits are kept in locked cabinets in the Assisted Living nurse’s station and in the Memory Care nurse’s station.