Routine inspection (multi-day)·April 21, 2025

Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced Annual Continuation Visit to the facility to continue the annual inspection visit initiated on 02/25/2025. Upon arrival, the LPA was greeted by staff who then contacted the Administrator, Anna D. Lee telephonically. The Administrator arrived at approximately 10:22 a.m., and at this time, the reason for the visit was explained. Entrance interview. During today’s visit, at 10:24 a.m., the LPA along with the Administrator toured the physical plant areas to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: The LPA inspected the kitchen area at 10:28 a.m. The facility has a sufficient supply of perishable and non-perishable food. The LPA observed furniture in the common areas to be in good condition. The facility maintained a comfortable temperature. The LPA observed required postings by the main entrance. There is a fireplace in the living room; adequately screened. The LPA observed six (6) resident bedrooms, which were furnished appropriately and had sufficient lighting. The LPA observed two (2) resident restrooms, which were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The LPA observed cameras in the common areas and outside perimeter. All indoor and outdoor passageways were free from obstructions in case of an emergency. No bodies of water noted at the time of the visit. Report Continued on LIC 809C... Report Continued from LIC 809... Records: Records review began at approximately 10:35 a.m. Five (5) resident records were reviewed for, but not limited to: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current appraisal. All resident files were in order. Three (3) personnel records including the current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Files were complete. Administrator’s Certificate is active until 01/11/2027. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. Documents were observed to be reviewed and updated annually as required. The facility’s policies and procedures as it pertains to infection control are adequate. Fire extinguisher was observed to be fully charged and serviced on 10/08/2024. Emergency disaster drills are conducted quarterly; last drill was conducted on 03/03/2025. Medications: Medications review began at approximately 11:55 a.m. Medications are centrally stored in a locked cabinet adjacent to the kitchen. Medications appeared to be given as prescribed. Exit interview conducted. No citations issued. Report was reviewed and a copy was issued.