Routine inspection·June 30, 2025

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. The purpose of the visit was explained to Rosario Munoz, Executive Director. The facility is licensed to serve for a capacity of 41 residents (34) ambulatory, maximum of (7) non-ambulatory restricted to Braemar cottage. Facility served elderly ages 60 and above and may retain (6) hospice residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Bathrooms have hygiene items such as paper towel, hand soap and toilet paper. Staff are adhering to infection control requirements. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan. Facility maintains the required liability insurance which expires on 03/12/2026. Surety Bond in the amount of $5000 is in effect. Physical Plant/Environment Safety: There are 6 different cottages (Lambert, Ramona, Foskett, Shafer, Armstrong, Braemar, and Jameson) and each contains resident rooms, living room, small dining room, kitchen, and a laundry room. The main dining room and kitchen are located at the Armstrong building. LPA randomly selected resident rooms to inspect. They are clean and have the required furnishings. LPA did not observe a signal system in place. There are no items obstructing the walkways. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. No large bodies of water were observed. There are no security bars or weapons on the premises. The facility has central air and heating accommodations.The hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines. Storage areas for cleaning solutions, toxic, knives, and hazardous items were secured in a shed and made inaccessible to residents. The fire extinguishers were observed to be fully charged and in compliance, however some of those were not mounted on the wall. The facility has carbon monoxide detectors in each cottage. A shaded area with chairs is provided to the residents. *****CONTINUED ON LIC809-C***** Staffing: A total of 22 staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Personnel Records-Training: Administrator certificate is valid and expire on 04/07/2026. Staff have criminal background clearance and training. (4) staff files were reviewed. Proof of staff training, health clearance, food handling certificates, and 1st Aid/CPR training are current. Resident Rights-Information: A total of (4) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, Individual Needs/Service Plans, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, medication records, and P & I money records. RCFE complaint poster and Personal rights were observed posted. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted in the dining room and in each cottage. The facility has a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed. Incidental Medical and Dental: Medications are centrally stored and locked in the medication room located in the Jameson cottage. Resident medications which are centrally stored were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided. Resident Records-Incident Reports: Resident files are kept in a secured location and have the following documents in their files: Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least (2) relocation sites. Facility conducts fire drill at least quarterly for each shift. Last fire drill was conducted on 03/17/2025. Residents with Special Health Needs: There are (2) residents receiving hospice care in the facility. Staff provide support care and supervision appropriate to meet the need of the residents receiving care from a Hospice agency. Technical violations were issued. An exit interview was conducted, and a copy of this report was provided to Rosario Munoz, Executive Director.