Routine inspection (multi-day)·April 17, 2025

Licensing Program Analyst (LPA) Kimberly Ramirez and LPA Blanca Gonzalez conducted a subsequent annual inspection visit on 04/17/2025 and was greeted by Administrator Diana Medina. LPA Ramirez conducted initial annual inspection on 03/25/2025 and due to time restraints, LPA needed to return another to complete annual inspection. LPA Ramirez identified herself and explained the purpose of the visit. The facility is located on a main street and has multiple dwellings. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Residents with Special Needs : Large bodies of water were observed and were observed to be fenced and inaccessible to residents. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Emergency pull cords were tested and were observed to be in working order. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication room and in bubble packs and/or original containers. LPA Ramirez observed Centrally Stored Medication and Destruction Record. The facility provides incidental medical services. Staffing: Administrator Certificate for Diana Medina 10/12/2025. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for five (5) out of the five (5) personnel record reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for five (5) out of the five (5) personnel record reviewed. Infection Control: Staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: Licensee may serve elderly residents age 60 and up. Approved for 100 ambulatory and 85 non-ambulatory. 20 non-ambulatory in 1st floor of main building and 32 non-ambulatory on the 2nd floor of the main building. 33 non-ambulatory in memory care building. Approved for delayed egress. This facility may retain no more than eight (8) hospice residents. Resident Records/Incident Reports: LPA reviewed resident records for eight (8) residents in care. Resident records are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. No deficiencies were observed during this visit. Exit interview conducted. A copy of this report was provided via email.