Facility Evaluation Report

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to conduct a case management – legal/non-compliance visit. LPA met with General Manager (GM), Billy Mitchell. The purpose of the visit to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on June 13, 2024.

During visit, LPA toured the facility with staff to include garden house (aka memory care), plaza, common areas. There were 7 staff members total on schedule during the AM shift in the Garden House. LPA reviewed the facility's roster on Guardian and observed the 14 staff members are fingerprint cleared and associated to the facility.

In Garden House, LPA randomly entered into rooms 127, 126B, 126A, 125B, 120, 115A and 101A with the Garden House Director. All the cabinets observed secured. No observation of accessible sharp objects, chemicals, disinfectants, and hygiene products to residents in care with dementia.

In Plaza, LPA randomly entered into rooms 304, 302, 203, 202, 209, 211 with the GM. No issues were noted. Residents who store their own chemicals, disinfectants and hygiene products are able to store these items per their physician's report/records.