Facility Evaluation Report

Licensing Program Analysts (LPAs) Kelly Dulek and Angela Barutyan conducted a pre-licensing change of ownership visit to this property at 09:45AM. During the course of the visit, deficiencies were observed and addressed with the current Administrator Denise Gilroy, and designees Agnes Gazaryan and Gloria Morales.

Facility tour began at 10:45AM. Hot water was measured in a sample of six (6) resident rooms. Temperature readings were inconsistent throughout the facility, measuring between 83.4 degrees Fahrenheit and 131.0 degrees Fahrenheit. Designee informed maintenance staff and called a plumber, who visited the facility during the visit. Water temperatures were adjusted during the visit.

At 10:47AM, LPAs facility designee observed an unlocked drawer in the memory care common area, which contained wound cleanser, lotions, shaving cream, and other various personal care and grooming items. Staff holding the key was called to the area to secure the items during the visit. One (1) resident's room in Assisted Living was observed dirty, with feces on the toilet. Designee called housekeeping and requested additional cleaning in this resident's room. A light in a common bathroom, as well as one in the 200's hallway were observed flickering and/or too dim for sufficient visibility. Maintenance replaced the light bulbs during the visit.

LPAs observed the two (2) delayed egress points at the end of the Memory Care hallways leading to the outside patio were not turned on during the visit. There are two (2) additional delayed egress points upon exiting the Memory Care patio, which were tested and functional at the time of the visit. LPA Dulek called and spoke with Fire Inspector Richard Martinez at 02:38PM, who indicated he will review facility layout, fire codes and contact LPA with an update on permissible use of the delayed egress.