Routine inspection·February 9, 2026

Licensing Program Analyst (LPA) Alberto Lopez conducted the required annual inspection. LPA arrived unannounced and met with Denise Sutton, Supervisor. LPA discussed the purpose of the visit. The facility is licensed to serve 124 non-ambulatory residents over the age of 60, with a hospice waiver for 16 residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: 1. Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting the clients. Staff are cleaning and disinfecting each shift for high touched surface area. Facility has sufficient PPE supplies and and an Infection Control Plan. 2. Physical Plant and Environmental: The facility is in a residential area and consists of a multi-level building with a dining room, library area, a commercial kitchen, resident rooms, a medication room, two (2) courtyards, a patio, a smoking area in the first floor. The second floor has a seating area, a TV room, an activity area, and several resident rooms. There is a total of three (3) stairwells. The baseman consists of staff offices, a therapy room, a laundry room, a beauty parlor, and staff break rooms. Each resident' room has a private bathroom. LPA inspected the carbon monoxide/smoke detectors in random rooms and are working probably. Facility tested the general fire alarm during the visit. LPA tested the hot water temperature, and tested between 109.9 –117.3 degrees F. which are within the Title 22 regulation of 105.0 – 120.0 degrees F..All the cleaning supplies and chemicals are locked and inaccessible to residents. The facility has sufficient personal hygiene products for clients to use. All clients rooms are completely furnished with chairs and have required beddings. All the bathrooms are clean, sanitized, and operational. The exit and passageway are safe and free of obstruction. One of the eaves by the stairway #3 leading outside needs to be repaired (continued on 809C) (continued from 809) 3. Operational Requirements: The facility maintains a fire clearance approved by the fire department. Currently the facility is licensed for 124 non-ambulatory and has hospice waiver for 16. The facility has shaded area with table and chairs for residents to utilize for outdoor activity. The last fire/disaster drill was conducted on 12/09/2025 LPA reviewed and verified facility liability insurance which expires on 01/01/2027 4. Staffing : The facility has sufficient staff, and the night supervision staff did receive planned emergency training. 5. Personnel Record-Training: All the staff files are maintained in the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. The administrator Rabie Bnafshesha certificate will be expired on 11/02/2025. All the direct care staff received Medication Management Training. The first aid training certificates for staff are current. 6. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. 7. Resident Rights-Information: The Complaint, ombudsman and Residents personal rights are posted by the main entry. Visiting hours are posted at facility. 8. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. 9. 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. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents. (Continued on 809C) (continued from 809C) 10. Incidental Medical & Dental: The medications are centrally stored in original containers. During the visit today, LPA reviewed five (5) residents' medication files, and all medications are administered according to Doctor’s orders. Two (2) of one residents PRNs were missing labels. 11. Disaster Preparedness: The facility has an Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, The facility conducts emergency drill on a quarterly basis for all staff. Facility needs to update emergency disaster plan to include two (2) relocation locations. 12. Residents with Special Health Needs : No residents have prohibited health conditions. No deficiencies observed during today’s visit. Technical Violations issued. An exit interview was held. A copy of this report, technical violations, and appeal rights were provided.