Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Required 1 Year visit and met with Executive Director (ED), Jeff Brenner. Facility has an approved dementia care plan. There are currently 42 residents in Assisted Living area and 29 residents in Memory Care Unit for a total of 71 residents in care. There are eight residents receiving hospice care services within the approved hospice waiver. Required postings were observed. Annual fees are current.

LPA/ED toured the facility which included an inspection of assisted living and memory care, all common areas, hallways, and bathrooms observed had sufficient lighting. During the walk through of the two story building including assisted living and memory care, LPA/ED noticed that garbage cans located in resident's bathrooms do not have lids, LPA had a conversation with ED regarding the importance of providing garbage cans with well-fit covers (technical advisory issued). There is a home health room located in the assisted living area. Residents rooms are furnished per regulation.

LPA/ED observed the memory care unit is on a delayed egress system, which it was approved in their fire clearance. The memory care area has outdoor entrance that has a door bell that it is accessible to families who gets access to the building through them. There are evacuation chairs located at each stair. The elevators were last inspected on 3/28/25. The facility was a comfortable temperature. Passageways were free of obstructions. Cleaning products are in locked closets or on supervised and/or locked carts. Facility has a sufficient supply of cleaners, hygiene items and paper products. Multiple first aid kits were observed. A call button is located in each bathroom, LPA tested the call system in resident's rooms and staff response time was under two minutes. Continued on LIC 809-C...