Routine inspection·May 30, 2025

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced required 1- year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. LPA Bunker met with Administrator Gwen Craig and Social Worker Elizabeth Hernandez and explained the purpose of today's Annual Inspection. LPA Bunker verified the facility has an approved mitigation plan report and infection control plan. The facility currently has 57 residents in placement. The facility is licensed to serve elderly residents aged 60 and above. The fire clearance is for 60 ambulatory and 36 non-ambulatory residents. LPA Bunker verified five staff fingerprints that were cleared and associated with the facility. The facility's annual fees are current. 12 Domains in the Infection Control Practices will be observed and reviewed. "I will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections." The above facility is a single-story business building located in a residential neighborhood. LPA Bunker and Administrator Gwen Craig toured the facility's main office/receptionist areas, administrator office, medication room, nurse station, dining room, break room, kitchen, male and female's restrooms, public restrooms, activity room, hair salon, bar shop, janitor closet, storage closet, storage units, laundry room located on the other side of the parking lot, patios, shaded area, and indoor/outdoor activity areas. During the visit bedrooms and bathrooms #2, #5, #8, #9, #15, #16, #20, #21, #38, #39, #43, #43, #44, #52, #54, and #55 were observed. See continued LIC809-C page 2. Continued LIC809-C page 2 Documents have been diligently posted as mandated on the wall in the receptionist areas, nurse station, dining room, break room, and hallways. The following Title 22 regulated areas were audited and found to be in compliance: Bedrooms contain the required furniture, and bathrooms are clean and operational. Personal accommodations were observed for safety, privacy, and comfort, including the provision of non-skid surface mats. The kitchen was observed for its ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage; there was an ample supply of perishable and nonperishable food. The resident’s medications were reviewed for proper storage, documentation, and PCC system implementation. Medications are securely locked in the medication room, records are current and up to date. Common areas observed for the ability to safely serve the needs of the residents, including cleanliness, and clear of any potential hazards to the residents. The first aid kit is fully stocked with manual, smoke, and carbon monoxide detectors were in compliance, the hot water temperature was measured within normal limits in the main building at (105), and in the bungalows as follows: #1 at 108, #2 at 107, and #3 at 110 degrees Fahrenheit (within the range of 105-120 degrees Fahrenheit). The fire extinguishers are fully charged, adequate linen supply, and the facility's telephones are tested and found to be in working order, The resident's bedroom windows have no sliding window lock with thumbscrews, all exit doors were found to be in compliance, the yard was free of debris hazards, and trash cans were covered. Staff members have undergone training on reporting dependent adult and elder abuse. The facility conducted a fire drill on May 12, 2025 LPA Bunker provided Administrator Gwen Craig with a copy of the facility evaluation reports. There were no deficiencies cited. An exit interview was conducted.