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25 | At approximately 9:25AM, Licensing Program Analysts (LPAs) Felias and Frank arrived unannounced to conduct a Required 1 Year visit and met with Executive Director, Shawn Mooney, and Assisted Living Director, Tess Estilo. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance for a total capacity of 130 individuals, where 81 individuals can be Non-Ambulatory and 15 can be Bedridden. Facility has an approved hospice waiver for 10 individuals. Upon arrival, LPAs was informed that there were 97 residents in Assisted Living and Memory Care with 25 Independent Living residents for a total of 122 residents in care. LPAs was also informed that there were 36 staff members on-site.
At approximately 9:45AM, LPAs reviewed Facility Staff Roster with Executive Director and Assisted Living Director and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 10:15AM, LPAs conducted a walk-though of the facility with Executive Director and Assisted Living Director and observed the following: Facility is a 3 story building for Assisted Living and Memory Care, and has separate Independent Living units on the property. Facility was clean and at a comfortable temperature with all exits free from obstruction. Facility has a infection control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Hot water temperatures for a sample size of 12 sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility's fire extinguishers were last inspected April 2024. Facility's smoke and carbon monoxide detectors and sprinkler system were last inspected May 2024. Facility's last emergency/disaster drill was conducted September 2024. Administrator's Certificate for Shawn Mooney (7021863740) is current with an expiration date of 03/10/2026. LPAs reviewed staff files. Files were all found to be well organized, thorough and contained the required documentation. Staff were found to have current First Aid and CPR certification.
LPAs unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date.
Exit interview conducted. Copy of report discussed and provided to Administrator/Executive Director. Signature on form confirms receipt of documents. |