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25 | At approximately 9:15AM, Licensing Program Analysts (LPAs) Felias and Florio arrived unannounced to conduct a Required 1 Year visit and met with Executive Director, Sam Faye, and Regional Health and Wellness Director, Roschelle Factor. 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 126 individuals, where 118 individuals can be Non-Ambulatory and 8 individuals can be Bedridden. Facility has an approved hospice waiver for 15 individuals. Upon arrival, LPA was informed that there were 69 residents in care and 23 staff members on-site.
At approximately 9:45AM, LPA reviewed Facility Staff Roster with Executive Director and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 10:30AM, LPA conducted a walk-though of the facility with Executive Director and observed the following: Facility is a 3 story building for Assisted Living and Memory Care. Facility was found to be 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 10 sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit.
LPAs reviewed Assisted Living Resident files. Resident Files were all found to be well organized, thorough and contained the required documentation.
Facility's fire extinguishers was last inspected April 2023. Facility's fire sprinklers were last inspected January 2024. Facility's last emergency drill was conducted March 2024.
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 Executive Director/Administrator. Signature on form confirms receipt of documents. |