Facility Evaluation Report

Licensing Program Analyst (LPA) Simi Rai arrived unannounced to conduct a case management – legal/non-compliance visit. LPA met with Business Office Director, Cristine Rivo and stated the purpose of today's visit.

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. LPA Rai reviewed facility files pertaining to the Corrective Action Training Plan created in response to the Non-Compliance Conference.

During today's visit, LPA toured the facility with staff to include Garden House/ Memory Care Unit, Plaza/Assisted Living unit, and common areas. There were 10 staff members total on schedule during the AM shift in Plaza, and Garden House. LPA reviewed the facility's roster on Guardian and observed the 10 out of 10 staff members are fingerprint cleared and associated to the facility.

LPA Rai toured 5 random rooms in Garden House and in Plaza and did not observe resident having access to sharp objects, chemicals, disinfectants, and hygiene products to residents in care with Dementia and did not observe any issues related to residents having access to sharp objects, chemicals, disinfectants, and hygiene products to residents who are able to do so per their physician's reports/records.