Facility Evaluation Report

At approximately 9:40 AM, Licensing Program Analyst (LPA) Magdaleno arrived unannounced to conduct a required 1-year annual inspection and met with Health and Wellness Director (HWD) Ieshaa Ragland. Facility is a Residential Care Facility for the Elderly (RCFE) with one hundred and sixty one (161) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for fifteen (15), and is approved for two hundred and forty two (242) non-ambulatory residents of which six (6) may be bedridden and forty five (45) may reside in Memory Care.

At approximately 9:50 AM, LPA initiated a tour of the facility with HWD and observed the following: Facility is a three (3) story building with "B" side consisting of three (3) levels of Assisted Living and "A" side consisting of two (2) levels of Memory Care with the third (3rd) story being additional Assisted Living. Facility was a comfortable temperature, and passageways were free from obstructions. Facility's fire extinguishers were observed charged and last serviced 10/25 . Smoke and Carbon Monoxide detectors were last inspected 11/25 by a third party vendor. Water temperature measured between 105.2- and 114.8 degrees F in a spot check of eight (8) assisted living bathrooms, one (1) assisted living shared bathroom, four (4) memory care bathrooms, and two (2) memory care shared bathrooms, which is within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. LPA observed at least a two (2) day supply of perishable and seven (7) day supply of non-perishable food, as well as an emergency water supply. Food was found to be stored in a safe manner with open items covered. LPA observed vegetables/pasta sauce that showed signs of spoilage including the growth of white/green substances (deficiency cited).