Facility Evaluation Report

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

During visit, LPA toured the facility with staff to include Garden House ( memory care unit), Plaza, common areas. There are 2 Med Techs and 4 caregivers in Assist Living for AM shift and PM shift. There are 4 caregivres and 1 Med Tech for Memory Care unit for AM shift and PM shift. LPA reviewed the facility's roster and observed the 11 staff members are associated to the facility.

In Garden House, LPA randomly entered into rooms #101A, #100, #102A, #101B, #103, #104 and #106A with GM. 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 #227, #226, #225, #223, #222, $216, #214 with 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.