Routine inspection·May 21, 2025

On May 21, 2025, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Cheresa Reyes. LPA explained the purpose of today’s visit. The facility is licensed to operate for six (6) ambulatory of which (2) may be bedridden elderly adults ages 60 and above. The facility is approved for four (4) hospice waivers. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident's rooms, two (2) bathrooms, a living area, a dining area, a kitchen, and an outside patio area. LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. A water temperature of 108. 0 . A comfortable temperature of 75 degrees F.was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished during the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained adequately. A fire extinguisher was charged, and smoke detectors and carbon monoxide were operable. A review of Medication Records Administration (MAR) and Fire Drills were observed to be maintained in order and accurate. The facility conducted Fire/Safety Drill on 05/01/25. The facility has a working landline telephone. The staff had all current CPR/First Aid Training on file. (Evaluation Report continues LIC 809-C) During the visit, LPA observed the facility's infection control practices. LPA observed staff followed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). Posters mandated for inspection control were posted. An audit of residents #1-#6 (R1-R6) service records and staff #1-#5 (S1-S6) personnel records revealed to be complete. The facility is current on CCL annual dues. The facility has administrator certificate that is current pending status for renewal with CDSS. DEFICIENCIES: At 2:50 PM, LPA observed rear toilet used for resident's daily activities is non-operable. Resident room #3 is missing a window screen. Deficiencies cited during this inspection visit is on LIC 809D. An exit interview conducted with Cheresa Reyes and a copy of the report is provided.