The facility was a single building, multi-floor facility with a combination of assisted living and independent living sections. The AAD informed the LPA that the facility had 229 residents in care at the time, including 27 in Assisted Living and 202 in Independent Living.

LPA initiated a walk-through of the facility, accompanied by AAD.

LPA inspected randomly selected resident rooms in Assisted Living and Independent Living. 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. LPA inspected the private bathrooms in these 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 116.4°F and 118.9°F.

LPA inspected the fire extinguishers mounted on the hallway walls in Assisted Living and Independent Living and found them fully charged, with the last service tag dated 09/04/2024. All common areas were free from obstructions, and hallways were well-lit. The smoke and carbon monoxide detector are tested daily by facilities technicians and yearly by a third party vendor, PAFA, with the last testing completed on 10/18/2024.

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 room was inspected and found to be clean, with all furniture in good repair.

LPA observed recreational rooms such as activity rooms, fitness centers, library, swimming pool, and auditorium for events, movies, and other activities. The residents were seen actively engaged in recreational programs and activities.

Continued on LIC809-C

LPA reviewed six (6) staff personnel records and five (5) resident records. The LPA observed that 5 of 5 residents had the Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, and CSDMR. LPA observed that 6 of 6 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 6 of 6 staff members were associated with the facility.

LPA observed a locked centrally stored medication cart located near the nursing station in the Assisted Living floor. Medications were organized in separate bins for each resident. All medication bottles and bubble packs were properly labeled. Centrally Stored Medication Records (CSMR) were reviewed and found to be complete.

LPA inspected the first aid kit and found it fully stocked. Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster Drills were conducted monthly, with the most recent drill completed on 03/12/2025.

The following updated forms are requested to be submitted to CCLD by 03/27/2025:

• LIC 500: Personnel Report
• LIC 308: Designation of Facility Responsibility
• LIC 400: Resident Cash Resources Affidavit
• LIC 402: Surety Bond
• Certificate of Liability Insurance
• Administrator Certificate(s)

An exit interview was conducted with the Assistant Administrator. A copy of this report was provided to the Assistant Administrator, Beth Shirley, whose signature on this form confirms receipt of the report.