Routine inspection·November 19, 2025

Licensing Program Analyst (LPA) Angela Barutyan arrived unannounced to conduct a required annual visit at 10:08AM. LPA met with staff, Administrator Doris Almario who arrived shortly thereafter, and Licensee Dina Vetchtein who arrived at 10:32AM. Entrance interview conducted. LPA and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN/LAUNDRY/GARAGE: LPA toured the kitchen at 10:16AM. Knives and chemicals are locked inaccessible. Kitchen appliances were in operable condition. The facility had a sufficient supply of perishable and non-perishable food. The garage attached to the kitchen is kept locked and contains two (2) additional freezers and extra supplies. The laundry room by the kitchen contained locked and inaccessible cleaning supplies, disinfectants, and detergents. BEDROOMS: The facility has seven (7) bedrooms total of which four (4) are single-occupancy resident rooms, one (1) is a shared resident room, one (1) is currently rented as a private resident living room, and one (1) is a staff room. All bedrooms were furnished appropriately; beds had clean linens and rooms had sufficient lighting. All direct exits were clear, no obstructions were noted. Staff room was observed locked. RESTROOMS: The facility has seven (7) restrooms. Five (5) out of six (6) resident bedrooms have an attached restroom, there is one (1) private restroom in the hallway, and one (1) staff/visitor restroom located by the laundry room near the kitchen. The restrooms were clean, sanitary, and in operating condition with grab bars and slip-resistant surfaces. Hot water temperatures were measured in resident bathrooms and were between 108.3-119.3 degrees F, which is within the required range. Report Continued on LIC809-C. COMMON AREAS: These include the living room and dining area. All common areas were observed to be in good condition. There is a screened and inaccessible fireplace in the living room. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were tested at 10:36AM and were operational at the time of the visit. The two (2) fire extinguishers were fully charged and were last purchased on 09/18/2025. LPA observed required postings throughout the common areas. Hallways contained supply closets with extra linens and emergency food and water supply. All auditory exit devices in common areas and bedrooms were functional and operating at the time of the visit. OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for resident use. There is a side gate for resident use that is single-latched. No bodies of water noted. RECORD REVIEW: Beginning at 10:40AM, LPA reviewed five (5) out of five (5) resident and three (3) personnel files for documents including but not limited to: medical records, care plans, resident Admission Agreement, TB test, health screening, staff training and fingerprint clearance. All resident and personnel files were in order. MEDICATION REVIEW: At 12PM, LPA reviewed medications for two (2) residents. Medications are centrally stored and locked in a cabinet in the kitchen area. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs were properly documented and logged. Medications were observed to be properly documented on the centrally stored medications and destruction record and were in compliance with regulation, state, and federal law. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency drills are conducted quarterly as is required, with the last drill conducted on 09/05/2025. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.