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25 | Licensing Program Analysts (LPAs) Kimberly Lyman and Fred Arias made an unannounced visit to conduct the required annual inspection. LPAs met with Executive Director (ED) Rosa Ayala and explained the reason for the visit. The facility is a three story building which consist of 30 units on the first floor reserved for memory care residents, and 16 additional units on the second floor for memory care residents. The capacity of the facility is 180 non-ambulatory and a hospice waiver for thirty five and bed ridden waiver for thirty five. There are currently a total of 134 residents, 46 of them are in memory care, and 14 on hospice. Rosa Ayala's Administrator's Certificate is in process of renewal as of 12/23/24. LPAs observed the PUB 475 poster (See Something, Say Something Poster) posted by the resident mail box. The PUB 475 poster posted is 20" X 26." LPAs observed the kitchen is clean and organized. There is a two day supply of perishable food and a seven day supply of non-perishable food on-hand in the kitchen. LPAs observed the emergency food and water. LPAs and ED toured resident rooms on three floors of the facilities. LPAs and ED toured the resident rooms in memory care unit area. LPAs inspected twelve resident rooms. All resident rooms had the required furnishings. All resident bathrooms were clean and operational. At 9:58am, one out of twelve resident rooms observed had PRNs in the bathroom. LPAs tested the emergency alarms and observed the staff came promptly when alerted. The hot water in the twelve resident rooms inspected measured 112.4 degrees Fahrenheit to 117.3 degrees Fahrenheit. LPAs observed residents participating in exercises in the activities room in the memory care area. There is fitness room and activities room for all residents. There is an outdoor courtyard for residents to sit outside. In the outside area there is a garden for residents to plant things. There is a pool area secured with a gate. Residents can utilize the pool as long as they are accompany with a staff who is water safety certified or a family member. In the summer they have water aerobics. There are fire extinguishers on every floor and all fire extinguishers are fully charged. LPAs observed emergency evacuation chairs in each stairwell. The last emergency fire drill was conducted on 1/29/25. The fire safety system is inspected annual every year by an outside agency, The last inspection was 8/30/24. LPAs reviewed twelve resident files with no discrepancies. All resident files had the required documents.
Continued on LIC-809C 2/4/2025 |