Facility Evaluation Report

At approximately 8:55 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a 1-Year Required inspection. LPA was greeted by Administrator, Anne Nakiyuka at 8:40 AM. Enso Village, a Kendal Affiliate serves older adults in Independent living, Assisted Living and Memory Care. The facility is licensed as a Residential Care Facility for the Elderly-Continuing Care Retirement Community (RCFE-CCRC). The Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and total capacity for four hundred (400) non-ambulatory residents. The facility has an approved hospice waiver for ten (10) residents. The facility consists of multiple buildings, all of which are inter-connected by paved walkways. LPA was informed that there were 307 Residents in care. At approximately 10:30 AM LPA reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation.

At approximately 11:00 AM LPA toured the facility with Administrator Nakiyuka. The facility was observed to be clean, orderly, and at a comfortable temperature during today's visit. All common areas, hallways, and bathrooms observed by the LPA had sufficient lighting. Bathrooms observed had grab bars, and non-slip mat/flooring for bathing/showering as needed. The facility has emergency supplies, including food and water to meet requirements of the 72-hour shelter in place. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. The facility offers a wide variety of menu options for the residents at each meal. There is a main dining room and a smaller dinning room available for assisted living residents. There is also a separate kitchen offering strictly vegetarian and vegan options for residents. Snacks are available to residents at all times. The Facility has a sufficient supply of cleaners, hygiene items, PPE supply, and paper products. All toxins/cleaners were locked and inaccessible to residents in care. Hot water temperatures for a sample size of fifteen (15) sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. All stairwells had evacuation chairs per regulation. Continued on 809-C...