Routine inspection (multi-day)·October 3, 2025

Licensing Program Analysts (LPAs) Cynthia Chan and Elena Mallett conducted a subsequent visit to continue the annual inspection. LPAs met with Administrator, Samantha Alex, to explain the reason of the visit. LPAs inspected the following domain of the CARE tools. Staffing : Per licensee, there is sufficient staffing at the facility and backup staff if needed. Staff employed have fingerprint clearance and associated to the facility. Personnel Records-Training : LPA reviewed 3 staff files and all documents are in file. Staff have current CPR/first aid training. Resident Records-Incident Reports: LPA reviewed 5 resident files and the following documents are found - admission agreements, Identification & Emergency Information, Physician's Report, Consent forms, Resident rights, and Safeguards for Personal Property/Valuables form. Resident Rights-Information: The Complaint poster, Local Ombudsman, and Residents personal rights are posted. Incidental Medical & Dental: The medications are centrally stored and locked in the kitchen drawers. Resident medications were reviewed and there were discrepancies found. Resident #3 did not have the physician's order for medication Risperidone. Resident #4 had an extra bubble pack of Lorazepam which appeared to be given with the other meds. Resident with Special Needs : There are currently no residents with a prohibited or restricted health condition or using oxygen. A deficiency was issued today. Exit interview was held. A copy of this report was given to the administrator.