Brush Creek Assisted Living

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Christi Coppo arrived announced to conduct a pre-licensing inspection and was greeted by applicant Savannah Arroyo. Facility currently does not have residents in care. Facility has fire clearance for fifteen [15] ambulatory residents. Applicant will submit proof of required liability insurance. At approximately 9:30am LPA and Applicant toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA advised need for emergency supply of non-perishable food and water. Kitchen has door with locking capability. Kitchen range has induction heating. LPA advised of food storage regulation 87309(a)(1) which requires all toxins and disinfectants, and cleaning solutions to be stored separately from food and food supplies. Facility is a single story building with nine [9] bedrooms: three (3) are single occupancy and six (6) are double occupancy. All bedrooms had bed, nightstand, and chest of drawers present. All rooms but one need a chair added. LPA advised of regulation 87303(a)(3)(B) which also states that each room should have a lamp or light sufficient for reading. Window screens need to be present in all rooms. Additionally, all facility doors leading to the exterior need to have an auditory alert device added to monitor exits on exterior doors and perimeter fence gates, applicant will add before licensure is granted. Rooms #8 and #9 will be dedicated as a live-in staff room, until facility is at full capacity. Facility also has activity area and an additional dedicated activity room, laundry room, kitchen, office area, and dining area. Facility has five (5) full bathrooms and one (1) half bath. All bathrooms are shared. LPA advised applicant of regulation 87303(a)(3)(C) which states the use of common wash cloths and towels is prohibited. Some of the bathrooms have the required grab bars, others do not. Applicant will add all required grab bars to showers and toilets before licensure is granted. Applicant showed LPA brand new non-skid mats that will be placed in bathrooms upon resident occupancy. Facility has automatic sensor Continued on 809C... Continued from 809... faucets present in bathrooms, which do not have designated cold and hot water options. LPA discussed with applicant the need for water to be at a temperature between 105 degrees F and 120 degrees F. Applicant will adjust faucet settings so that when activated, water dispenses at a temperature within regulation 87303(e)(2). LPA did get one water reading in kitchen of 129.8 degrees F. LPA advised temperatures which are within regulation fall within 105 & 120 degrees F. Water temperature readings must be within regulation before licensure. Facility utilizes well water, but applicant was advised per their CAB analyst that a bacterial analysis is not required because the resident will be provided filtered water for drinking. However, LPA discussed applicant sending analysis for facility file. Facility has an east and west corridor. Facility has two (2) designated fire exits, one off each corridor. LPA observed emergency shut off valves for water and gas. LPA discussed with applicant identified items which could present as possible safety hazards to residents. Facility has small step in the west corridor that could pose as tripping hazard. Applicant advised LPA they will look in to creating a graduated slope to minimize risk. Small step or lip also present in entrance to bathrooms #1 and #2, applicant will add something to remove tripping hazard. Facility has gas line pipe exposed in the west corridor, nail head exposed. Applicant will add cover to gas line pipe before licensure. Facility has large outside area for residents to enjoy. However, fence on has minor holes and one board in disrepair. Applicant will fix fence, repairs very minor so repair not required before licensure. Facility has two designated shaded area for residents to utilize and a wrap around eave. LPA observed fire/smoke alarms to be hardwired and operational. It was not clear if carbon monoxide detectors were part of the hardwired fire/smoke alarm system. Applicant will submit proof of combo system or add carbon monoxide detectors before licensure. Applicant advised LPA that they will be adding surveillance cameras to the facility via RIng. LPA advised there is no regulation for video surveillance. However, LPA advised that video cannot include audio and must be disclosed to all residents and responsible parties. Additionally, LPA advised that video is only permitted in common areas and cannot be used in lieu of adequate staffing. Continued on 809C(2)... Continues from 809C... Four (4) extinguishers present and last serviced on 10/7/25. First aid kit present with all required items. LPA observed all required postings and posters present. Night lights in hallway present. LPA reviewed LIC601E and Infection Control Plan. Applicant states that most recent LIC610E submitted to CAB analyst has Temporary Shelter Locations listed. Applicant will forward updated LIC610E if LPA not able to get updated page from CAB analyst. Items to be added as residents fill vacant rooms: lamp, chair, emergency water and food supply, and enough food for each resident such that there is enough for a 2 day supply of perishable and a 7 day supply of non-persihable food. Items required to be repaired/addressed before licensure: All bathrooms have grab bars present for showers and toilets Water temperature readings within regulation All facility doors leading to the exterior need to have an auditory alert device present Proof of combo fire alarm/carbon monoxide system or add carbon monoxide detectors Applicant to notify CCL once all repairs complete. LPA will then return to inspect the above items before recommending applicant for licensure. Comp III reviewed and completed. Exit interview conducted with applicant and a copy of this report given.the state’s words, verbatim · CDSS document, Jul 21, 2026