Routine inspection·March 27, 2026

Licensing Program Analyst (LPA) Vaid conducted an unannounced annual visit to the facility. LPA met with Andrea Mazariego,caregiver and explained the reason for the visit. Administrator Clemencia Bousheri was notified and arrived at the facility shortly after. The facility is licensed to serve fifteen (15) non-ambulatory residents, ages 60 and above, and had six (6) Hospice Waiver approved. Current census is 15 residents, and 4 hospice residents. LPA reviewed the following CARE inspection tool domains during this visit: 1.Infection Control: Infection control plan was reviewed which meets current regulations. Hand sanitizer and proper sanitation were observed during the visit. There is a responsible person and emergency training was provided for staff. Personal protective equipment was observed. 2.Operational Requirements: Facility maintains a plan of operation. Facility is operating within the license. Facility has current liability insurance, expiration 03/26/2027. 3.Physical Plant/Environmental Safety: LPA conducted a tour of the facility with Andrea Mazariego and observed the following: Facility is a single home located in a residential neighborhood. The home consists of a lobby area/ office, a kitchen, a family room, a dining room, 10 resident rooms (5 private and 5 shared rooms), 5 resident bathrooms, 1 staff bathroom, a laundry area, a front porch, a back yard consisting of the patio and garden. Facility was observed in good repair indoors and outdoors. All common areas are clean, and provide sufficient sitting area, and lighting. Kitchen area is clean; sharps were observed locked in a box. Medications were observed locked in the office. Cleaning supplies were observed to be inaccessible to residents in the laundry room. Laundry area was observed in good repair. LPA observed 6 random resident rooms, each in good repair, with all bedding supplies, and sufficient lighting. Five bathrooms were observed all in good repair, with grab bars, and non-slip shower floors. (CONTINUED ON LIC 809C) Water temperature was tested in the resident bathrooms between 107.2 to 112.8 degrees F., which is within the required temperature. Carbon Monoxide/Smoke detectors were tested and are in working condition. Fire extinguishers were observed and last checked on 09/23/2025. The backyard has a shaded covered area. 4.Staffing: Staff have current CPR/First Aid training on file. Night staff have been provided with emergency training. Sufficient staff were observed. 5.Personnel Records/Staff Training : Administrator certificate was observed for Clemencia Bousheri exp. date: 4/5/25. Renewal documents have been submitted to the department. All staff records were available for review. LPA reviewed a total of 5 staff files which included medical assessment, TB clearance, background clearance, and initial and yearly training. 6.Resident Rights/Information: Personal Rights, Let Us No, and Local Ombudsman posters were observed throughout the home. 7.Planned Activities: Activity materials were observed. Outdoor area has a seating area and activity supplies to promote outdoor activities. 8.Food Service: Sufficient food supplies were observed for perishables for at least 2 days and 7-days non-perishables. There are residents with special diets, and staff prepare meals accordingly. No pests were observed within the interior and exterior of the facility building. 9.Incidental Medical and Dental: Medications are centrally stored in the office. Medications are labeled and in their original containers. LPA reviewed medication for 6 residents. 10.Resident Records/Incident Reports: Residents records were available for review. LPA reviewed a total of 6 resident files which contained medical assessment, TB clearance, admission agreement, appraisal, needs and care plan. 11.Disaster Preparedness : Emergency Disaster plan (LIC 610E) was last reviewed on 01/01/2026 and an emergency disaster plan was reviewed. Emergency drills are conducted monthly, last drill was on 03/05/26. 12.Residents with Special Health Needs: There are no residents with restricted health conditions under care. Facility follows dementia regulations. Medical assessments for residents with dementia were observed within the last 12 months. Auditory devices were observed at each exit door. Facility currently has four residents on hospice and keeps hospice plan on file. No deficiency were observed on todays’ visit. Exit interview was conducted with Administrator and a copy of this licensing report was provided.