Routine inspection·January 16, 2026

Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with staff, and explained the reason for the visit. Administrator, Reynaldo Del Rosario could not attend the annual for the day due his exposure to COVID. Assistant Administrator Catherine Del Rosario, came in his place. At approximately 09:25 am, with the assistance of staff, LPA took a tour of the physical plant. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks were observed in the entry area. LPA tested the smoke alarms and carbone monoxide and they were function properly.. LPA observed the fire extinguisher in the kitchen with purchase date Jan 12, 2026. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. The laundry area is located adjacent to the kitchen. LPA observed laundry was locked and all toxins are inaccessible to residents. Bedrooms: There were five (5) bedrooms designated for residents' use. Four (4) bedrooms are designated for private use, and one (1) room is shared. All five bedrooms, in use by residents, were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are three (3) bathrooms designated for residents' use. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 106.5, 113.0 and 108.7 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection. Common Areas : These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. (Continue on 809 C) The dining room table is large enough to sit the capacity of the facility. Seating such as couches where in good repair and sit the capacity of the facility. Surrounding Grounds : Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. LPA checked the gates at both sides of the home to ensure no locks were installed, and that exits and passageways were clear for emergency evacuation. Resident Files: LPA reviewed resident records and observed the following deficiencies: Resident #1 (R1) and Resident #6 (R6) files did not contain physician reports. R1 had full bed rails in place and was not receiving hospice care. Residents #2 (R2), #3 (R3), and #4 (R4) had half bed rails without physician orders. Resident #2 (R2), #3 (R3), and #5 (R5) files did not contain an Appraisal Needs and Services Plan. Resident #1 (R1), #4 (R4), and #5 (R5) files did not include a Safeguards for Property and Valuables form (LIC 621). Additionally, Resident #6 (R6) did not have a hospice care plan on file. Staff Files : LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Medications : Medication and Medication Records were not consist. LPA was unable to audit medications due to inconsistency and incomplete records for all the residents. Temperature: Facility maintains a comfortable temperature of 74 degrees Fahrenheit Exit interview conducted, citations issued, appeal rights given and copy of this report signed and delivered.