Routine inspection·September 26, 2025

At 10:00a.m., Licensing Program Analyst (LPA), Antonia Alvizar-Ettima and Regional Manager (RO), Angela Whittaker conducted a Required One (1) Year Annual visit. LPA and RO met with Manager and granted entry. Staff called the Administrator, and the purpose of visit was stated. Later the Administrator/Licensee joined us. At about 10:35a.m., LPA, RO and manager conducted a tour of the physical plant. Required postings were observed throughout the facility. This is an RCFE with a capacity of 199. The census is currently 103. The facility consists of a three (3) floor building with a total of 100 resident bedrooms (50 bedrooms on the second level and third level), each having its own bathroom. The first floor consists of the following: a lobby area, administrative offices, function room, dining area, activities room, television room, laundry room, staff lounge, family visiting room, guest restrooms, storage rooms, kitchen, and a sitting garden. There are two operable elevators, one designated for residents and the other for staff. The temperature of the facility wall thermostat was set at 72°F and observed to be within required range. The most recent fire and disaster drills were conducted on 09/03/2025. Care and supervision to meet the resident’s needs was observed. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools during the inspection and observed the following: Bedrooms: Bedrooms in the 2nd floor has non-ambulatory residents and the 3rd floor has ambulatory residents. Bedrooms were toured and observed to be clean and properly furnished with appropriate dresser, bedding, and linens with sufficient lighting. Linen storage was also checked and observed to have an ample supply of clean linen and towels. Cont. on LIC 809-C Bathrooms: Bathrooms were observed to be properly supplied and working fixtures, with appropriate grab bars, and non-slip mats were present. Hot water temperature was measured at a range of 109.9°F to 113.1°F which meets Title 22 regulations. Adequate supply of hygiene supplies available stored in supply room. Emergency Phone numbers, exit plan and menu: Posted and readily available for review in the lobby floor hallways. All fire extinguishers are fully charged with service tag date of 06/25/25. Smoke Detectors: Resident rooms and common areas have a manual smoke detector. Carbon monoxide detectors are located in each facility floor hallway. Fire inspection including smoke detectors, bells, door magnets, strobes, mini horns and full fire inspection was last done on 04/16/25. Common Areas : These include a lobby area, function room, dining area, activities room, television room, staff lounge, family visiting room, physical therapy room, guest restroom, and a sitting garden. There are two operable elevators, one designated for residents and the other for staff. The common areas were properly furnished. Furniture in common areas was observed to be in good repair. No obstructions or tripping hazards throughout the facility. Kitchen: Kitchen was observed to be clean and sanitary and free of pets. The kitchen appliances and fixtures were functional. Food : LPA observed at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. All food was properly wrapped, labeled, and stored. Food storage and preparation areas are clean and inaccessible to pests. Knives, cutlery and other sharp kitchen utensils are stored in the kitchen and only accessible for staff. All toxins and cleaning agents are locked in storage rooms. Laundry Room: Located on the 1 st floor and inaccessible to residents. Detergent is kept in the laundry room locked. All toxins were stored and locked in the supply room. Surrounding Grounds : Entry and exits were free of obstruction. Outdoor areas were clean, with appropriate furniture and no hazards noted. The facility does not have a swimming pool or other body of water. Due to time constraints, LPA were unable to complete today's annual inspection. LPA will complete the inspection at a later date. There was no immediate health or safety hazard were observed. Exit interview conducted and a copy of this report was provided.