Routine inspection·August 26, 2025

Licensing Program Analyst (LPA) Kimberly Ramirez and LPA Gabby Castro conducted an unannounced required annual inspection visit and was greeted by MedTech Elvira Cortez. LPA Ramirez explained the purpose of the visit. The facility is located on a main street and is a single store dwelling. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) resident rooms. All resident bedrooms contained the required furniture, linens and lighting. Water temperatures in grooming and bathing areas were measured to be over 120 degrees F. Resident bathroom#8 water temperature was measured to be 123 degrees F. LPA Ramirez will issue type A deficiency based on this observation. LPA Ramirez observed postings encouraging proper hand washing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed non-slip mat in showers. Showers were observed to be wheelchair accessible. Food Service: LPA Ramirez observed a sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C). See 809-C Planned Activities: LPA Ramirez observed staff conducted seated activities with residents during inspection. Facility employs a full-time activity director to plan and carry out activities for residents. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed the facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. The last documented emergency drills were conducted on 05/2025. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed an emergency food supply. Residents with Special Needs : No large bodies of water were observed. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices and delay egress perimeters were observed to be in working order. LPA Ramirez pulled emergency cords in rooms#4 and 7. After waiting a few minutes, staff did not respond and LPA Ramirez asked to see the location of the main signal system. LPA Ramirez and med tech Elvira Cortez observed the main signal box was not "powered on" and was unplugged. Staff advised LPA Ramirez that sometimes residents will sometimes unplug the signal system. LPA Ramirez will issue a type B deficiency based on this observation. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication cart and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) electronic log to document medications given. Staffing: Administrator Certificate for Laura Hernandez and it expires 08/25/2026. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. see 809-C Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed some required annual training, CPR and First Aid for four (4) out of the four (4) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for four (4) out of the four (4) personnel records reviewed. Staff#3 (S3) & staff#4 (S4) did not have sufficient annual required training hours on dementia, postural supports, restricted health conditions and hospice care as required by 1569.625(b)(2). LPA Ramirez observed some of the documented in-service trainings did not document the numbers of hours. LPA Ramirez will issue two (2) type B deficiencies based on this record review. Infection Control: They’re using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for forty (40) non-ambulatory, of which ten (10) may be bedridden. This facility may retain no more than twenty (20) hospice residents. The facility currently has nine (9) residents on hospice care. Resident Records/Incident Reports: LPA reviewed Resident files for four (4) residents. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. Four (4) deficiencies were issued. Exit interview conducted. A copy of this report, 809-D, and appeals rights were provided.