Routine inspection·February 13, 2025

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to conduct the Required Annual Inspection. LPA met with Administrator Jethronel Lazaga. LPA disclosed the purpose of the inspection and was granted entry into the facility by Staff. Staff contacted Administrator via telephone who responded to assist with the visit. A tour of the facility was conducted with the Administrator. Residents' rooms were toured and inspected and observed to be clean. Hot water temperature was measured from 133.9. Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked Medication closet. LPA observed medications on office desk. Office is not a locked room making medications accessible to residents. One of R1's medication was not logged on centrally stored log to indicate whether or not R1 is receiving medications as prescribed. Cleaning supplies were in a locked storage closet in the garage. Facility has a pull station fire alarm. Fire extinguishers were charged and had service dates of 1/06/25. Smoke detectors and carbon monoxide were operating. There was outdoor seating for the residents under a covered patio. Facility has a pool that is gated and locked, making it inaccessible to residents in care. Resident, medication and staff records were reviewed. Current first aid and CPR were on file for staff. Refer to 809D An exit interview was conducted with the Administrator. A copy of this report, plan of correction and appeal rights were provided.