Routine inspection·September 19, 2025

On 09/19/2025, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conducted a annual inspection. Upon arrival LPA met with the Wellness Director- Chhandita Panday who was informed of the purpose of today’s visit. Administrator Catalina Cole arrived at 9:00 AM and she was also informed of the purpose of todays visit. The facility is licensed to care for (50) non-ambulatory residents ages 60 and over and approved for(15) hospice waivers. The facility is a two-story structure located in a commercial neighborhood. It consists of the following: (50) resident bedrooms, (50) resident bathrooms and (4) public restrooms, dining room, laundry room, business offices,kitchen,outdoor patio,salon,medication room,and an employee lounge. The facility temperature ranged from 73 - 79 degrees F. At 9:00AM, LPA Allen and Catalina toured the physical plant. There were no bodies of water on the premises. At 9:15AM, LPA Allen and Catalina inspected bedrooms #101, #110, #216, #218 and #232 the bathrooms were operational with water temperature measured at 105.2 – 107.9 degrees F. The bedrooms have the required furniture such as beds and bedding supplies which appeared to be in good condition,there is adequate lighting provided, and storage for the resident's personal belongings Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and inaccessible to residents. Continued.... The kitchen was inspected, and there was a 5-day supply of perishable and a 7-day supply of non-perishable food items available, which were adequately maintained and stored there was also a menu available for review. The fire extinguishers, carbon monoxide detectors and smoke detectors were fully charged and operable. The last fire drill was 9/2/2025. At 11:45 AM, LPA Allen reviewed four (4) residents’ files for admission agreements, updated physician reports, and needs and services plan which appeared to be up to date. LPA Allen reviewed four (4) staff files to verify First Aid/CPR certification, criminal record clearance, and health screenings. All reviewed items appeared to be current and up to date. However, during the review of staff files for S1, S2, S3, and S4, no annual training records were available for review and not in compliance with Title 22, Division 6, Chapter 8. Based on the observations made during today’s visit, a deficiency was cited. An exit interview was conducted where this report LIC809, 809-C and LIC809D was discussed and provided to Catalina Cole- Administrator at the conclusion of the visit with appeal rights.