Routine inspection·September 16, 2025

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit. LPA was met by Primitivo Serame, DSP I & II and Cherry Serame, DSP I & II and explained the purpose of the visit. The Administrator was called on the phone who informed LPA that she is out of the area and unable to assist. The facility is licensed to care for (4) residents ages 60 and above and one may be bedridden. Bedridden fire clearance approved for bedroom #1 only. Approved to care for (4) hospice residents . LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Bathroom has hygiene items such as paper towel, hand soap and toilet paper. Staff are using appropriate hand hygiene and wearing gloves while assisting residents. Operational Requirements: A fire clearance is in place. Facility has working signal systems in exit points. Liability Insurance policy is valid and will expire on 02/15/2026. There are (2) fire extinguishers in the facility which was last serviced on 02/18/2025. Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood that consists of (7) bedrooms, (3) bathrooms, living room with a fireplace, kitchen, dining area, family room, laundry area in the hallway, backyard with sitting area and attached garage. The facility is only using the bedrooms to the right of the house for residents, of which (3) bedrooms are for residents, (1) for staff, and (2) bathrooms. The other side of the house consists of 3 bedrooms dedicated as staff rooms and (1) bathroom. garage. Currently, th ere are two (2) residents in the facility. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, linen, light, chair and sufficient closet space. There are (2) carbon monoxide detectors at the home . Backyard was inspected and does not have a shaded area. There are no firearms or weapons stored at the facility. Water temperature reading measured 107.6 deg F in bathroom #1 and 109.2 deg F in bathroom #2 which is within the required 105 - 120 degrees Fahrenheit. *****REPORT CONTINUED ON LIC809-C**** Staffing: A total of five (5) staff members including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility. Personnel Records/Staff Training: Administrator's proof of health clearance, fingerprint clearance, vaccinations and 1st Aid/CPR training are current. Administrator's certificate is valid and expires on 05/31/2026. Resident Rights-Information: Rights of individuals with disabilities are posted. Facility provides internet services to all residents and have access to the facility phone. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. LPA observed that some food containers inside the refrigerator were not covered nor labeled. Incidental Medical Services: Medications reviewed for (2) residents. Residents have Restricted Health Care Plan and Needs and Services Plan on file. Currently, (1) resident is under hospice care and (1) resident receive Home Health care in the facility. Residents medication are centrally stored in a locked cabinet in the kitchen area. Resident Records-Incident Reports: Two (2) resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records, Restricted Health Care Plans and Hospice Notes/Records were reviewed. During medication review, LPA observed the staff failed to sign/initial the Medication Administration Record (MAR) on the correct dates, 09/15/2025 (PM) and 09/16/2025 (AM) for the medications administered for (2) residents. Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. The facility conducts emergency drill on a quarterly basis. Last fire drill was conducted on 07/18/2025. Residents with SHN : One (1) resident receive hospice care. Appraisals were observed in resident files. Deficiency cited and Technical Assistance issued. Exit interview and a copy of this report along with the appeal rights were provided to Cherry Serame, DSP II.