Routine inspection·March 11, 2026

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced for a required one-year annual inspection. The LPA met with staff, Martina Bwalya and advised them about the visit. Staff called the Administrator Irene Saroyan, the LPA explained the reason for the visit. The Administrator informed the LPA that they were not feeling well and that they would be available via telephone if the LPA had any questions. Administrator said that staff would sign off the visit report. The LPA stated that they would call the Administrator back when the inspection was completed and would read the report to the Administrator over the phone. The LPA along with the staff 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. COMMON AREAS: At the time of the visit, the living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 77 degrees. The smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguishers were observed to be purchased on 03/11/2026. The LPA observed required postings throughout the common space. There is a working telephone on premises, however the phone number listed in the Community Care Licensing (CCL) database FAS is disconnected. The LPA advised the Administrator to update the facility number as soon as permitted through Guardian system. Working auditory alarms were observed in all exit doors at the time of the visit. Night lights were present in the hallways. The facility has a sufficient amount of emergency food and water. The LPA observed a sufficient supply of Personal Protection Equipment (PPE). LPA observed cameras in the common areas, and throughout the exterior perimeter of the facility. KITCHEN: Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates and food labels had expiration date clearly marked. The knives and sharps stored in a locked drawer inaccessible to residents in care. Cleaning supplies were also observed locked and inaccessible under the kitchen sink. Continues on LIC 809C... BEDROOMS: There are four (4) resident bedrooms. Two (2) bedrooms are single occupancy, and two (2) bedrooms are double occupancy. Bedroom # 2 is currently empty. The LPA observed the resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. At the time of the visit bedroom #1 and bedroom#4 were occupied as shared rooms. RESTROOMS: There are two (2) resident restrooms. The first restroom is located in the main hallway and the second restroom is located in bedroom #4. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. Hand washing signs were observed inside the bathrooms. The hot water temperature was measured in both bathrooms; the first bathroom measured 118.3 degrees; and the second bathroom measured 119.5 degrees. LAUNDRY ROOM: The washer and dryer were observed inaccessible to residents in care in a locked room adjacent to the kitchen. Laundry detergents were observed locked and inaccessible inside the laundry room. OUTDOOR AREA: The backyard has a covered patio area equipped with furniture for resident use. Emergency exits and passageways were observed free of obstruction. No bodies of water were noted at the time of the visit. The property is gated. LPA observed the gated door to be single action lock. GARAGE: There is a detached garage located on the property. The LPA observed garage to be locked and being used as a staff office. Office was inaccessible to residents in care at this time. RECORDS: Records review began at 12:20 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the annual appropriate training. All files were in order. MEDICATIONS: Medications review began at 1:30 p.m.; medications are centrally stored and locked in a cabinet in a locked file cabinet by the hallway ; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.The LPA reviewed the following documents: - LIC500 Personnel Report-LIC9020 Client Roster-Certificate of Liability of Insurance - Emergency Drill Logs No deficiencies cited. Exit interview conducted. A copy of the report was issued.