Routine inspection·October 28, 2025

On 11/28/2025, Licensing Program Analyst (LPA) M Vega arrived to the facility unannounced to conduct the annual visit. LPA met with S1 which granted LPA's entry into the facility. LPA shortly met with Licensee Camalah Kopacz. Facility has one entrance/exit point. LPA toured facility with Licensee inside and out. The facility was observed to be at a comfortable temperature, of 77 degrees F. Facility is free of debris, in good repair, and no passageway obstructions or fire hazards were observed. Common areas were properly furnished and well-lit throughout. LPA observed residents though out the facility. Department phone number and infection prevention information signs were posted thought the facility. Inspecting kitchen LPA observed the required 7-day supply of non-perishable food and 2-day supply of fresh perishables to be properly stored. An emergency disaster supply was observed. Fire extinguisher was observed with a service date of 7/01/2025. All 3 residents’ bedrooms were observed to be with comfortable temperature. Water temperature in restroom was recorded at 108.6 degrees F. Medications observed to be locked in a cabinet in laundry area. LPA reviewed medication records and there were no deficiencies at the time of inspection. Cleaning supplies were observed to be in a locked cabinet under the kitchen sink and in the laundry room. An outdoor seating area was observed for residents in care. Back yard was free from obstructions to fire exit. LPA reviewed Staff and Resident files. Resident files observed to have updated information. Continuation on LIC 809C No deficiencies were cited during inspection. Exit Interview conducted. LPAs requested documents to be submitted to the department by 11/11/25: current Administrator certificate, LIC 308, LIC 400, LIC 402, LIC 500, LIC 610E, LIC 9020, and updated facility sketch. A copy of this report was provided to Licensee, whose signature on this form confirms receipt of this report.