Routine inspection·June 6, 2025

Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with staff Carmelita Terminez Aliga and explained the reason for the visit. Administrator was contacted by phone and LPA was informed that Administrator is out of town. LPA advised Administrator that w hen the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility. Staff Carmelita Terminez Aliga was designated to sign off the report. At approximately 11:30 am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. Smoke alarm and carbon monoxide system were tested and observed not operational. The fire extinguisher is located in the kitchen and there were no indications of the service date or the purchase date. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. Bedrooms: The facility has four (4) bedrooms, which only two (2) rooms are in use by residents, and the other two (2) are not occupied. All bedrooms are properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 109.8 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection. Temperature: Facility maintains a comfortable temperature of 75 degrees Fahrenheit. Common Areas : These included the living room and dining area. The common areas were properly furnished. (Continue on 809 C) Surrounding Grounds : Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. Laundry Area : is located in the garage, which is inaccessible to residents. Garage: LPA inspected the garage and observed that it is used only for storage. LPA observed additional fridge and storage boxes. Medications : Medication and Medication Records were review for proper documentation. Resident Files : LPA conducted a file review of resident records to ensure compliance of licensing forms. LPA observed that Admission Agreement for Resident 3 was incomplete. Staff Files : LPA also conducted a file review of staff records and observed that there is no physical file for Staff #1 (S1) and Staff#2 (S2) is not associated to the facility and missing LIC 501 form. Staff was unable to provide LIC 500 as per Administrator is not update. Administrator advised that requested will be emailed to the LPA promptly. Exit interview conducted, Civil Penalty and other citations Issued, Appeal Right given and copy of this report delivered.