Routine inspection·August 18, 2025

Licensing Program Analyst (LPA) Alberto Lopez conducted the required annual inspection. LPA met with Zara Poghosyan, Director of Operations. and discussed the purpose of today’s visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility uses appropriate hand hygiene and wearing gloves while assisting residents. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for (85) ambulatory and (14) non-ambulatory residents aged 60 and above. Non-ambulatory residents in first floor bedrooms only. Hospice Waiver approved 15 residents. Last Fire Drill was conducted 07/30/2025 Staff are adhering to operational requirements. Staffing : There is sufficient staffing at the facility. Administrator Certificate for Anna Rempel on file has an expiration date of 06/11/26. 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 reviewed staff files for Facility Administrator and Staff 1-5 (S1) - (S5). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained in Abuse Reporting and Resident Rights. Staff have on-going training. Resident Rights-Information: RCFE complaint poster and Personal rights were observed posted in the facility as well as LTCO poster. Per Facility Administrator, facility provides wi-fi services for facility residents. (See LIC809C for the continuation of this report) Resident Records-Incident Reports: LPA reviewed Resident files for R#1 - R#8. Resident files 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, Functional Capabilities, Appraisal/Needs and Services Plan, Resident Rights were observed. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place but needs to be updated. Physical Plant & Environment Safety: LPA conducted a tour of the physical plant areas inside and outside to ensure there are no health and safety hazards, and that facility follows Title 22 Regulations. The physical plant tour was conducted with the assistance of Zara Poghosyan, Director of Operations. The physical plant consists of a two-story building with 52 rooms with bathrooms in each room, offices, lobby, TV Room/ Activity Room, 2 dining rooms, kitchen, storage, laundry and outside patio. Resident rooms were randomly chosen for inspection and LPA observed that resident bedrooms have the required furniture, bed linens, sufficient lighting and closet/drawer space to accommodate each resident comfortably. Private resident bathrooms in rooms were inspected. Restrooms were clean, toilets and water faucets worked properly and were properly supplied, have functional fixtures and have secure grab bars, showers were free of mold/ mildew and most had non-skid mats or strips in place. Hygiene supplies are provided. Water temperature was measured in random resident’s rooms and temperatures ranged from 109.4 to 113.5 degrees F. which is within range of 105.0 – 120.0 degrees F. Resident bath towels, toiletries and personal hygiene supplies were adequately available. The fire alarm system requires maintenance as it could not be heard in the entire building. Some rooms had smoke alarms that were not operable at the time of visit. One room has a missing door on the bathroom vanity and the bathroom shelf was uncleaned. Planned Activities: Calendars and supplies for activities were observed in the activity room. (Continued on 809C) (Continued from 809C) Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. Additional food supply was also observed. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. The kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept clean and stored properly. The dining room has adequate seating. Posted menu observed. Health Related Services/Incidental Medical Services: The medications are centrally stored in the office/ medication room and in bubble packs and/or original containers. LPA reviewed medication for R1-R5. The facility uses the Medication Administration Records (MARs) to document medications given to residents. Medications are administered as prescribed by the Physician. The facility provides incidental medical services. Per Title 22 Regulations, there were deficiencies observed during the visit. Technical Advisory issued. An Exit interview and a copy of this report were provided to Zara Poghosyan, Director of Operations along with appeal rights.