Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the annual continuation. LPA met with Executive Director (ED) Zeinab Donner.

LPA entered the Memory Care unit with ED. Memory care is equipped with delayed egress doors. During visit, LPA observed residents participating in activities. Activities calendar observed posted in the hallway. Temperature maintained at 72 degrees Fahrenheit. LPA and ED entered into 5 resident bedrooms. LPA observed the bedrooms were equipped with adequate lighting, beds, linens, dressers, chairs, and night stands. LPA did not observe any items that could pose a danger to residents with Dementia accessible to residents. Resident bathrooms observed with non-slid floors in the shower and grab bars. Hot water temperature in the resident bathrooms of room C2, C3, and C21 maintained at 105 degrees Fahrenheit.

LPA entered the Assisted Living section with ED. LPA entered into room 244 and 229. Water temperature for both rooms maintained at 100 degrees Fahrenheit.

LPA reviewed 3 resident files in memory care. 2 out of 3 residents who are diagnosed with Dementia did not have an updated medical assessment. R1's medical assessment was last updated in 2021 and R2's medical assessment was last updated in 2022. 3 out of 3 residents files does not contain an signed and dated appraisal/needs and services plan. 3 out of 3 residents files contained a signed admission agreement, consent form, personal rights, safeguard of personal properties and valuables, TB result, and emergency/identification form. SEE LIC809-C.