Routine inspection·February 23, 2026

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Lydia Pabion, Administrator and explained the reason for the visit. Facility is licensed to serve 99 adults over the age of 60 years old, of which 35 may be non-ambulatory. Facility has a hospice waiver for 4 and the following rooms are cleared for bedridden residents; 102 thru 110, 115 thru 119, and 123. LPA observed the following today: 1. Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting the clients. Staff are cleaning and disinfecting each shift for high touched surface area. Facility has sufficient PPE supplies and but does have an Infection Control Plan. 2. Physical Plant and Environmental: Facility is a two-story building with a commercial kitchen, a dining room, an activity room, a courtyard, a medication room, a laundry room, front porch, and smoking area in the back. LPA inspected the carbon monoxide/smoke detectors in random rooms and are working probably. LPA tested the hot water temperature, and was tested between 105.4 –121.5 degrees F. which is not within the Title 22 regulation of 105.0 – 120.0 degrees F. All the cleaning supplies and chemicals are locked and inaccessible to residents. The facility has sufficient personal hygiene products for clients to use. All clients rooms are completely furnished with chairs and have required beddings. All the bathrooms are clean, sanitized, and operational. The exit and passageway are safe and free of obstruction. One soap dispenser is in need of repair, room 105 is missing slip mat, some window screens need repair, and one shelf in storage room needs replacement. Small trash can first floor restroom needs repair. (Continued on 809C) (continued from 809) 3. Operational Requirements: The facility maintains a fire clearance approved by the fire department. Facility Has hospice waiver for four (4) The facility has shaded area with table and chairs for residents to utilize for outdoor activity. The last fire/disaster drill was conducted on 02/03/2026. LPA reviewed and verified facility liability insurance which expires on 12/18/2026 4. Staffing: The facility has sufficient staff, and the night supervision staff did receive planned emergency training. 5. Personnel Record-Training: All the staff files are maintained in the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. The administrator Lydia Pabion certificate expires on 08/10/2027. All the direct care staff received Medication Management Training. The first aid training certificates for staff are current. 6. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. 7. Resident Rights-Information: The Complaint, ombudsman and Residents personal rights are posted by the main entry. Visiting hours were posted at facility. 8. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. 9. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents. 10. Incidental Medical & Dental: The medications are centrally stored in original containers. During the visit today, LPA reviewed five (5) residents' medication files, and all medications are administered according to Doctor’s orders. (continue on 809C) (continued from 809C) 11. Disaster Preparedness: The facility has an Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, The facility conducts emergency drill on a quarterly basis for all staff and residents. Facility needs to update emergency disaster plan to include additional relocation location. 12. Residents with Special Health Needs : No residents have prohibited health conditions. Deficiencies observed during today’s visit. Technical Violations and advisory issued. An exit interview was held. A copy of this report, 809D technical violations, advisory, and appeal rights were provided.