Routine inspection·September 6, 2025

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced annual inspection visit on 9/06/2025 and was greeted by Caregiver Antonio Santiago. Administrator Ana Duenas arrived shortly after. LPA Ramirez identified herself and explained the purpose of the visit. The facility is located on a residential street and is a single store dwelling. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be accessible to resident#1 (R1). Per R1's physician report, R1 may not have access to these items. Staff immediately removed these items upon LPA's observation. LPA Ramirez observed ZZZQuil supplement and Ultra Strength Sleep aid supplements on top of R1's nightstand. Per R1's physician report, R1 may not have access to these items. Staff immediately removed these items upon LPA's observation. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) resident rooms. All resident bedrooms contained the required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside shower. LPA Ramirez observed non-slip coating in showers. LPA Ramirez observed seated shower chairs in bathrooms. LPA Ramirez observed 2 discarded hospital bed frames blocking passageway access to from bedroom#3. Staff are throwing disposing R1, R3 and R4's used lancets in the trash can. LPA Ramirez observed bathroom cabinet drawer in bedroom#3 to be in disrepair and exposing sharp screws. See 809-C for continued narrative Food Service: LPA Ramirez observed a sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: personal rights, and nondiscrimination notice. LPA Ramirez observed Complaint Poster (PUB 475) was not 20”x26” as required. LPA Ramirez observed facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Proof of quarterly Emergency drills was not provided upon request. LPA Ramirez observed an emergency food supply located in pantry. Residents with Special Needs : No large bodies of water were observed 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. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication cabinet and in bubble packs and/or original containers. LPA Ramirez observed Centrally Stored Medication and Destruction Record. Staffing: Administrator Certificate for Ana Duenas with an expiration date of 07/26/2027. 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 did not observe the required CPR and First Aid training for three (3) out of the three (3) personnel record reviewed. S1 and S2 did not have the required annual training documented in their personnel file. LPA Ramirez did not observe S2’s health screening in their personnel file. 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: The fire clearance is approved for six (6) residents over the age of 59 years old, of which five (5) may be non-ambulatory and one (1) bedridden. This facility may retain no more than three (3) hospice residents. There were three (3) residents on hospice during time of inspection. Resident Records/Incident Reports: LPA reviewed resident records for six (6) 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. Fourteen (14) violations were observed and cited during this annual inspection. Exit interview was conducted with Caregiver Antonio Santiago. A copy of this report, 809-D and appeals rights was provided via email.