Roses Assisted Living

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at 10:10am to conducted a 1 year annual visit to the facility above. LPA met with Administrator Victoria Thorne and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out clipboard for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels and hand soap. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance. The facility is approved for a capacity of 6 with 6 Non-Ambulatory and Hospice approved for 4. Physical Plant & Environmental Safety: The facility is a 5 bedroom and 3 bathroom currently occupying 6 residents and employs 5 staff,1 Administrators and 3 back up staffing. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked in laundry room closet. The facility has sufficient space inside and outside for activities and visiting. The facility is on a hill and has a pond in the back yard with a metal grade cover, the back porch gate is locked not allowing access to the back yard or pond by residents in care. The facility has a front patio area for resident use. The facility has telephone and internet service for resident use. Continued 809-C Staffing: The facility employes 5 staff, 1 Administrator and 2 back up staffing. Staff records are kept confidential. Five files reviewed had current Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions. Administrator file was reviewed for continuing education and current Administrator Certificate expires 08/15/2027. Personnel Records & Training: The facility keeps confidential files for staff members. Staff have training of 20 plus hours completed from 2025-2026. Residents Rights and Information: CCL and LTCO Complaint posters are posted. The facility has a posting on the wall in the entry with all required postings posted. Planned Activities: The facility has a cupboard with puzzles, games, books for resident use. There is enough space inside and outside for activities. Residents take part in the activities they like to do. Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. Cleaning solutions and equipment are stored separately from food supplies. Kitchen staff are observed for personal hygiene and food sanitation practices. Kitchen stove/hood/oven, microwave and cupboards need additional cleaning. Incidental Medical and Dental Services: Facility provides or assists in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA checked medications for all 6 residents, medication labels were not altered, medications were stored in original containers and no medication were expired. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, LIC. 602A Physicians report, Pre-appraisals, Functional Capabilities Assessments, Appraisals Needs and Services Plan, Emergency and ID forms, all forms were legible and completed in separate confidential binders for each resident in care. Continued 809-C Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers was charged and last inspected on 04/16/2026. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility has no residents currently on oxygen. The facility has 2 hospice residents in care. Hospice care plans are kept on file and up to date. The facility does not currently have residents receiving Home Health services. Home Health services records are kept on file when needed. The facility does not have delayed egress. Exit doors have alarms. The back yard is inaccessible to residents in care due to being located on a hill and a water feature with a pond. The side yard has a patio with furniture and shade fully fenced with a locked gate to the back yard. The side yard has a hot tub that is empty and not in use hard wood cover, fully fenced with a lacked gate. Exit interview conducted, copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Sep 17, 2026

Type of visit: Required - 1 Year

At 9:30am, on 9/30/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct the annual facility inspection. LPA met with Administrator Victoria Thorne, announced who he was and the reason for the visit. Administrator and LPA conducted a full tour of the facility. This facility is a single-story residential home with five resident bedrooms (one is dual occupancy), two full shared/public bathrooms, and a third full bathroom on-suite to the dual occupancy bedroom. There is a living room, dining area, a kitchen and family room with a second dining space. LPA noted the living room has a fireplace that is not used per the Administrator. Access to the laundry room is through locked bi-fold doors for resident safety. There is a garage with locked cabinets and a locked office that contains medications and staff/resident folders. LPA noted that the backyard and the front yard both have seating and shade for residents and visitors. The backyard consists of two raised patio spaces and a lower lawn area. LPA noted the lawn area contains a fish pond covered with a metal barrier and accessed through locked barriers off of the two patios for resident safety. One of the two raised patio areas contains a partially above ground jacuzzi/pool that is not in use, has been permanently covered and only accessible through a locked fence for resident safety. The facility has battery operated smart dual smoke/carbon monoxide detectors in each room that are all working. LPA observed fire extinguishers throughout the facility that are tagged current and in the green compression range, serviced on 4/25/2025. LPA tested facility hot water at 108*(f), within regulation temperatures 105*-120* (f). LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods. (Continued on LIC809-C) LPA noted that the facility is clean and in good repair with no obstructions in hallways, doorways or exits. LPA conducted a sample medication audit and reviewed the facilities Centrally Stored Medication Records, staff, and resident files. LPA and Administrator conducted a review of the annual care tool modules. There were no deficiencies cited at this time. Exit interview conducted, report signed, and report provided to the Administrator.the state’s words, verbatim · CDSS document, Sep 30, 2025

The state marks this report as 8 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

At 10:00am on 09/23/2024, Licensing Program Analyst (LPA) Jeffies arrived unannounced to conduct the annual facility inspection. LPA met with Administrator, Victoria Thorne, announce who he is and the reason or the visit. Administrator and LPA conducted a physical tour of the facility. This is 5 bedroom, one room is a double resident occupancy, the other four rooms are single resident occupancy. There is a staff office where medications and facility staff and resident files are stored. There is a full kitchen dining room and two living rooms. There are outdoor spaces in the front and the back with awnings for shade. There is a current resident and staff roster available on request. The facility is maintained in conformity with State Fire Marshall regulations. Smoke alarms and carbon monoxide detectors tested and functioning in every room throughout the facility. LPA viewed 2 Fire extinguishers are fully charged. The facility has a spa that is gated and locked and with additional cover and pond with mesh top for safety. The Administrator is present a sufficient number of hours to manage and oversee the facility. Outdoor area toured, there are appropriate outdoor furnishings. All walkways are free of obstruction. There is an adequate amount of perishable and nonperishable foods. The facility maintains a comfortable temperature around 73 degrees. Hot water temperature was measured at in conformance with regulation standards. There are lamps/lights for each room to ensure safety and comfort for all persons in the facility. Residents are treated with dignity and respect by staff. Grab bars are available for each toilet and shower used by residents. Showers have non-skid mats. Items dangerous to dementia residents are inaccessible. Facility has a written and readily available disaster and infection control plan. There are at least 2 days of perishable foods and 7 days of nonperishable foods on hand for 6 residents and staff. All persons associated with the facility have criminal record clearance. Resident files reviewed have signed admission agreements, current physician reports and current appraisals. Administrator and LPA conducted a full review of the annual care tools. LPA noted that no citations or violations present during this annual facility inspection. Exit interview, report provided. .the state’s words, verbatim · CDSS document, Sep 23, 2024