Facility Evaluation Report

THIS IS AN AMENDED REPORT. Licensing Program Analysts (LPAs) Christine Dolores and Santino Fortes arrived announced to conduct the facility's pre-licensing inspection. LPAs met with Brenda Ritter (Regional Director of Operations) and Carol Pickard (Senior Executive Director). The facility's fire clearance is approved for 205 capacity in which 193 may be non-ambulatory and 12 may be bedridden. All rooms are approved for non-ambulatory / bedridden residents. The facility is connected to a commercial building and Gallery Cafe (located near the first-floor entrance) that is not part of the facility's license. According to the applicant, the café may be opened in year 2025 and the residents may have access to the Gallery café which is not part of the licensee or excluded from the license. Between the community and Gallery café can be accessed through a door (passageway) by a using a key card on the wall to enter both ways from inside the Café and in the facility. The applicant states the Gallery Café may or may not be employees of the facility. The applicant states that if they are employees of the facility, they will ensure compliance with Title 22. The applicant was informed that if they are not part of the facility’s employees that the staff who work in the Gallery Café should not be allowed inside the premises of the facility unless the individual is escorted or supervised by the facility staff. LPAs toured the facility with Brenda and Carol to include the exterior, underground garage, first, second, third, fourth, fifth, and sixth floor. All indoor and outdoor passageways and stairwells were free and clear of obstruction. There are 2 courtyard emergency exits doors that are able to freely open wherein they do not contain any locks that prevent the doors from opening. Stairwell #1 and #2 observed with an evacuation chair located on the fourth and sixth floor. Facility temperature maintained between 69 - 73 degrees F. Elevators observed to be in working condition. There is no swimming pool or other bodies of water observed. Adequate lighting are present in the hallways and common areas. Pull cord devices that includes an emergency call button observed throughout the facility were randomly tested in each floors and are operational. Applicant stated that resident calls are captured through a staff radio (pagers) and a list of calls are registered via PALCare Software. SEE LIC809-C.