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25 | At approximately 8:20AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Receptionist, Sony Pastor. Administrator/Executive Director, Stephanie Limberg, arrived during visit at approximately 8:45AM. Facility serves 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 and total capacity for 114 non-ambulatory residents of which 14 residents can be bedridden. Facility has an approved hospice waiver for 12 individuals. Upon arrival, LPA was informed that there were 102 Residents in care and 32 staff members on-site.
At approximately 9:10AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 9:55AM, LPA conducted a walk-though of the facility with Administrator. LPA observed the following: Facility consists of two buildings, one for Assisted Living, and one for Memory Care. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. 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 sprinkler system was last inspected March 2023. Facility's last emergency/disaster drill was conducted March 2024.
At approximately 11:55AM, LPA reviewed resident files. Files were all found to be well organized, thorough and contained the required documentation.
Administrator's Certificate for Stephanie Limberg (6015704740) was current with an expiration date of 07/06/2024.
LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date.
No Deficiencies Cited during visit.
Exit interview conducted. Copy of report discussed and provided to Administrator/Executive Director. Signature on form confirms receipt of documents.
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