Routine inspection·August 14, 2025

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced annual inspection visit on 8/214/2025 and was greeted by Administrator Leah Ignacio. LPA Ramirez identified herself and explained the purpose of the visit. The facility is located on a residential 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 all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside shower. LPA Ramirez observed non-slip mats in showers. LPA Ramirez observed seated shower chairs in bathrooms. 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 for continued narrative Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents. One (1) out of the three (3) residents at the facility attends an adult day program. 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. LPA Ramirez observed an emergency food supply located in pantry. During record review, LPA Ramirez observed emergency disaster drill logs were incomplete, as they had been left blank. LPA Ramirez will issue a deficiency based on this record review. 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. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices were observed to be in working order. During record review, LPA Ramirez observed R1 was admitted into the facility 4/19/2023 and was placed on hospice care on 7/17/2025. The facility currently does not have an approved hospice care waiver. LPA Ramirez will issue a deficiency based on this record review. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication cabinet and in bubble packs and/or original containers. LPA Ramirez observed Centrally Stored Medication and Destruction Record. The facility provides incidental medical services. SEE 809-C for continued narrative Staffing: Administrator Certificate for Leah Ignacio is expired, however, according to Administrator Leah Ignacio, she sent her renewal package months ago and is awaiting processing. LPA Ramirez was unable to locate pending administrator renewal when verified through internal processes. Per Administrator Leah Ignacio, substitute designee Administrator Laura Ignacio assists in her place. LPA Ramirez verified Administrator Laura Ignacio certificate (7005001740) expires on 07/25/2026. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed the required annual training, CPR and First Aid for one (1) out of the one (1) personnel record reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for two (2) out of the two (2) personnel record reviewed. Infection Control: Staff are 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 six (6) non-ambulatory residents over the age of 59 years old. During record review, the administrator was unable to provide the current Certificate of Liability Insurance. However, LPA Ramirez did observe a liability insurance binder with a policy number, policy liability limits and start date of liability insurance. LPA Ramirez will issue a Technical Violation. SEE 809-C for continued narrative Resident Records/Incident Reports: LPA reviewed resident records for three (3) residents in care. Resident records 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. According to Administrator Leah Ignacio, R1 had a recent hospitalization on 4/2025 due to an illness and on 7/17/2025 was placed on hospice care. During record review, LPA Ramirez did not observe an updated Care Plan/Appraisal/Needs and Services Plan for R1, after R1's recent hospitalization and significant change to needs and services care plan. LPA Ramirez will issue a deficiency based on this record review. LPA Ramirez did not observe a documented report that this licensing agency was notified in writing within 7 days of R1’s hospitalization. LPA Ramirez will issue a deficiency based on this record review. LPA Ramirez did not observe a hospice care plan for R1 during record review. Administrator Leah Ignacio placed a call to R1’s hospice agency and received a copy of R1’s hospice care plan within an hour. LPA Ramirez will issue a Technical Violation based on this record review. Four (4) deficiencies and three (3) technical violations were cited during this annual inspection. Exit interview was conducted. A copy of this report, 809-D, LIC 9102 and appeals rights was provided.