Facility Evaluation Report

At approximately 9:45 AM, Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to BEGIN a required 1-year annual inspection and met with Phyllicia Xiong-Assisted Living Director and Sonja Duerst- Clinical Service Director. Facility is a Continuing Care Retirement Community (CCRC) with a combined total of 72 residents currently residing in the assisted living and memory care units. The community is approved for a total capacity of 743 residents, of which 223 residents may be non-ambulatory. The community has a hospice waiver for 6 residents, and there is an approved delayed egress system in place in the memory care unit. Deer Creek Memory Care Unit has a current census of 16. Quail Creek Assisted Living has a current census of 32 and Willow Creek Assisted Living has a current census of 25.

At approximately 10:40 AM, LPA initiated a tour of the community's Quail Creek and Willow Creek Assisted Living Facilities and the Deer Creek Memory Care Facility and observed the following: The Quail Creek facility is a three story building and the Willow Creek and Deer Creek facilities are both one story. Each building was a comfortable temperature, and passageways were free from obstructions. LPA observed the required evacuation chairs in stairwells. Water temperature in 6 random resident bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. An staff service room in the Willow Creek Assisted Living unit, that is not readily accessed by residents was noted to have an odor and evidence of a warped and discolored melamine counter top and a technical advisory was issued to advise repair/replacement.

LPA observed a supply of hygiene, paper, and incontinent care products available for residents. Residents' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets and storage rooms containing cleaning supplies and other items that could pose a risk were locked. Community has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Food was covered, labeled, and stored in accordance with regulation. Medications were centrally stored and locked in all 3 building, including rooms and rolling lockable medicine carts.