Routine inspection·May 15, 2026

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA was met by Joel Basillo and Cathlyn Eroza, Caregivers and explained the purpose of the visit. The administrator, Terry McGenn was called to inform of the visit. At 10:25am, Barbara Boiston, House Manager arrived and assisted LPA. The facility is approved to serve residents age range 60 and above. Facility fire cleared for (2) ambulatory and (4) non ambulatory residents age 60 and above. Approved to accept or retain up to (6) residents on hospice. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Staff are trained in the proper use of all required PPEs prior to being around residents. Bathroom has hygiene items such as paper towel, hand soap and toilet paper. Operational Requirements: Facility has working signal systems in exit points. The facility has a dementia care plan to accept or retain residents with dementia. Staff have the required training to provide special care to dementia residents. Staff cannot provide a copy of the liability insurance during the visit. Physical Plant/Environment Safety: T he facility is a single story home located in a residential neighborhood which consists of (6) bedrooms, one of which is a staff bedroom, (3) bathrooms, living room with fireplace, family room with a fireplace, kitchen, dining room, laundry area and backyard with patio area. There are currently (5) residents, 60 years and older residing in the facility, (1) is under hospice care. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, linen, light, chair and sufficient closet space. LPA observed the large sliding door in the staff bedroom is impassable, completely blocked by stacks of boxes. LPA observed that the living room is used for sleeping which was confirmed by a staff member. The fireplaces are adequately screened and inaccessible to residents. Backyard was inspected and has a swimming pool surrounded by a locked gate. There are (2) fire extinguishers in the facility which were serviced on 04/15/2026. Sufficient food supplies of 2 day perishable and at least a week of non-perishable are observed. Knives, cleaning solutions, and disinfectants are locked. Smoke alarms and carbon monoxide were tested and operable. Hot water temperature reading measured within the required 105 - 120 degrees Fahrenheit *****REPORT CONTINUED ON LIC809-C***** Staffing: A total of (8) caregivers including the Administrator provide care and supervision to the residents. One (1) staff provides night supervision and can assist in caring for residents in the event of an emergency. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility. Personnel Records-Training: Four (4) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings. Administrator has completed the required Administrator courses and certificate is valid through 04/08/2027. Resident Rights-Information: Resident personal rights are posted. Facility provides internet services to all residents and have access to the facility phone. Facility provides initial and ongoing training for staff. Planned Activities: The facility provides sufficient space to accommodate both indoor and outdoor activities. Residents are encouraged to participate in a variety of planned activities. Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. LPA observed uncovered left over food in the refrigerator and food containers were not labeled. LPA also observed the preparation plastic bowls were stored along with cleaning supplies and other chemicals in a kitchen cabinet under the sink. Incidental Medical Services: Residents' medications were reviewed during the visit. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are stored in a locked cabinet and inaccessible to residents. Facility did not have an up to date prescribed and PRN medication list for the residents. Staff did not properly document the medications administered to the resident on the medication administration record (MAR). Resident Records-Incident Reports: Five (5) resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records. Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices. Fire drill conducted monthly, last fire drill was on 04/02/2026. Residents with SHN: (1) resident is under hospice care and one resident on oxygen. Physician orders for 1/2 bed rails were reviewed on the residents' files. Staff did not have training in the operation of the oxygen equipment. Deficiencies cited and Technical advisories issued. Exit interview and a copy of this report along with the appeal rights were provided to Barbara Boiston, House Manager.