The facility has an approved fire clearance for (89) non-ambulatory and (8) bedridden residents.

The facility is a four-story building with first, second, and fourth floor for Assisted Living and third floor for Memory Care. Assisted Living had 60 rooms and Memory Care had 28 rooms. The ED informed the LPA that the facility had 66 residents in care at the time.

At 10:25 AM, LPA initiated a walk-through of the facility, accompanied by ED.

LPA inspected randomly selected eight (8) resident rooms in Assisted Living and Memory Care units. The rooms were found to be clean, well-lit, and equipped with the required furniture. Emergency pull cords were observed to be functioning in the resident rooms with an average response time of 15 minutes. LPA inspected the private bathrooms in random rooms. The bathrooms contained soap, grab bars, towels, a trash can, and non-slip flooring. The hot water temperature at the sink faucets measured between 111.7°F and 116.4°F. “Oxygen in Use/No smoking” signs were observed posted outside the residents’ room where oxygen was administered.

LPA inspected activity areas, library, media room, Theater room, exercise room, and other commons areas and observed residents actively engaged in recreational programs and activities. Activity calendar was observed posted at various locations throughout the facility. All common areas were free from obstructions, and hallways were well-lit.

Continued on LIC809-C

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

LPA observed locked centrally stored medication carts in the Assisted Living and Memory Care units. Medications were organized separately for each resident. Narcotics were locked. All medication bottles and bubble packs were properly labeled. Centrally Stored Medication Records were reviewed and found to be complete.

LPA inspected the main kitchen and found it clean. The refrigerator, freezer, and pantry cabinets were checked, and there was a sufficient supply of fresh perishable food for two (2) days and nonperishable staples for seven (7) days. No expired food items were found. Open food items were wrapped and dated. The dining rooms in Assisted Living and Memory Care was inspected and were found to be clean, with all furniture in good repair.

LPA toured the outside patio area and found passageways in good condition, free of obstructions, and without any blocking or tripping hazards. The patio area had patio tables, chairs, and umbrellas for residents’ use. Delayed egress was observed on exterior exit doors. No accessible bodies of water were observed.

LPA reviewed five (5) staff personnel records and five (5) resident records, and found them complete.

LPA inspected the fire extinguishers mounted on the hallway walls in Assisted Living and Memory Care and found them fully charged, with the last service tag dated 01/06/2025. The Automatic sprinkler systems are tested quarterly and annually, with the last inspection completed on 03/12/2025. The smoke detectors are tested annually by a third-party vendor, Fortify Fire Protection. A staff member tested the carbon monoxide detector in the hallway in LPA’s presence, and it was found to be functional.

LPA inspected the first aid kit and found it fully stocked. Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster (Fire and Earthquake) Drills were conducted monthly, with the most recent drill completed on 05/15/2025.

COMP III was reviewed and completed with the Executive Director.

No issues were noted during the Pre-licensing inspection prior to the licensure.

An exit interview was conducted with the Executive Director. A copy of this report was provided to the Executive Director, Stephanie Brice, whose signature on this form confirms receipt of the report.