Facility Evaluation Report

Licensing Program Analyst (LPA) Kelly Dulek arrived unannounced to conduct a required annual visit. The LPA met with Executive Director (ED) Gena Grundeis and informed ED of the reason for the visit. Entrance interview conducted. ED indicated she has been working at the facility for approximately 2 and a half months, however the Regional Office did not receive notification in writing of a new ED within 30 days, per regulation. LPA discussed with ED paperwork required. All paperwork was provided during today's visit.

Beginning at 11:11AM, the LPA, along with ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. The following was observed:

The facility is a three-story building. There are resident rooms on all three floors, units are designated for independent living residents on the third floor, assisted living residents on all three floors and a separate secured unit on the first floor is designated for residents in the memory care unit.

Common Areas: There were no obstructions and/or tripping hazards observed during facility tour. The facility maintains a comfortable temperature throughout the building. There are fire extinguishers throughout the facility, which were fully charged and last serviced 11/02/2022. Hardwired smoke detectors, fire doors and sprinkler system are inspected monthly, with the most recent inspection completed on 06/05/2023. Planned activities are offered. Activity schedule is posted throughout the facility. All activity rooms and common spaces appeared clean and in good repair. Cleaning supplies and disinfectants are stored locked per regulation. At 11:16AM, a storage closet containing used sharps was observed to be unlocked and accessible to residents in care. A working telephone is present. The LPA observed the required postings in the common area.

Resident Rooms: The facility consists of shared and private resident rooms, of which the LPA observed 10