Routine inspection·November 13, 2025

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA met with Gabriel Abrera, Caregiver and Richard Rabena Jr., Administrator and explained the purpose of the visit. The facility is approved for (5) non ambulatory and (1) bedridden resident age 60 and up. Rooms #1 & 2 approved for staff and licensee, all other rooms are for residents. Room #7 is approved for bedridden, and approved for (2) hospice waivers. 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. Bathroom has hygiene items such as hand soap and toilet paper. The Administrator/licensee has not been reviewing and updating the use of infection control procedures at least annually in the facility. Operational Requirements: The facility accepts and retains residents with dementia . The plan of operation includes training for staff who provide dementia special care.Facility maintains liability insurance in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate which expires on 06/16/2026. Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood which consists of (5) resident bedrooms, (2) staff bedrooms, (3) bathrooms, living room, dining room, kitchen, and attached garage with an office area. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, linen, light, chair and sufficient closet space. There are no cameras in the facility. Smoke alarms and carbon monoxide were tested and operable. The facility has a carbon monoxide detector in the hallway. The facility does not have working signal systems in exit points. There are (2) fire extinguishers in the facility which was last serviced on 08/15/2025. Backyard was inspected and has a shaded area and sitting area. There are no swimming pool or bodies of water on the premises. The hot water temperature reading measured within the required 105 - 120 degrees Fahrenheit. Hot water readings were 110.6 deg F in bathroom #1, 117.5 deg F in bathroom #2 and 115.6 deg in bathroom #3. ****REPORT CONTINUED ON LIC809-C***** Staffing: A total of (6) caregivers including the Administrator provide care and supervision to the residents. There are sufficient staff to meet resident needs. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility. Personnel Records-Training: Staff files are maintained at the facility and were reviewed for criminal background clearance and training. Personnel records have health/TB screenings. Administrator's certificate is valid, expires on 07/27/2027. Staff have current CPR & first aid certificates. Administrator's first aid/CPR training expired on 11/01/2025. Resident Rights-Information: Resident personal rights are posted. Visiting policy is posted at a location that is visible and accessible to residents and families. Facility provides internet services to all residents and have access to the facility phone. Planned Activities: Information regarding Dementia is part of training for direct care staff and is included in the Plan of Operation. The facility provides sufficient space to accommodate both indoor and outdoor activities. Food Service: The kitchen was inspected and sufficient food supplies of 2 day perishable and a week of non-perishable are observed. Pesticides and cleaning supplies are kept away from the food preparation areas. Incidental Medical Services: Residents medications were reviewed to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications were stored in a locked cabinet and inaccessible to residents. Medications are administered as prescribed. Resident Records-Incident Reports: All (6) resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records. Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation. The facility conducts fire drill on a quarterly basis. Last fire drill was conducted on November 10, 2025. Medications of one resident needing refrigeration are stored in the refrigerator in the garage that were not in a separate container and not clearly labeled 'medication'. Residents with SHN: Currently, there are no residents under hospice care. (5) of (6) residents with 1/2 bed rail did not have a written order from their physicians in the resident's record. There are no hospice residents and there is (1) bedridden resident. Deficiencies cited, Technical violation and Technical Assistance issued. Exit interview and a copy of this report was provided to the Administrator, Richard Rabena.