Routine inspection·October 27, 2025

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA Lopez met with Licensee Rosalie Ngo and explained the reason for the visit. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The facility has an Infection Control Plan. Operational Requirements: A current Plan of Operation was reviewed. The facility serves residents 60 years and older, and a Hospice Waiver for two (2) resident is approved. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place. A surety bond is not applicable. Facility does not handle resident's money. Physical Plant/Environment Safety: Facility is in good repair indoor and outdoor. Kitchen is clean, refrigerator and freezer are in good repair. Sufficient food was observed for at least 2 days of perishables and 7 days of non-perishables. Sharps and medication are kept in the kitchen. Residents do not have access to the kitchen but are able to request any food item at any time. Each resident's room (8) was observed with sufficient lighting, required furniture, and bedding supplies. (continued on 809C) (Continued from 809C) Room #3 is being used by staff. Each bathroom (7) was observed in working condition, grab bars and skid mats were observed, and water temperature was tested between 105.9 -117.7 degrees F., which is within the required 105-120 degrees F. Cleaning supplies are kept in a lock closet in the hallway. Additional bedding supplies were observed. First aid is available with all the required items. Living room, dining room, and family room are clean and have sufficient seating space. Motion sound detector device was observed in the front door, door going to the laundry, and gate in the side patio. Cameras were observed in the common areas. Carbon Monoxide/Smoke detectors were observed and in working condition. One room did not have a smoke detector and staff promptly placed one in room. Fire extinguishers were last checked on 08/01/2024 Last fire drill was on 09/01/2025 and disaster drill was on 09/01/2025 Food Service: Sufficient food supply is stored in the kitchen and storage areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Staffing: There appears to be always sufficient staffing in the facility. With night staff that are trained and able to assist in care and supervision of the residents in case of an emergency. Personnel Records/Staff Training: Staff have criminal record clearance, current First-Aid training along with training in medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 5 staff files with no deficiencies observed. Health screening for one staff member is missing one page. Administrator Greg Tillman certificate expires on 10/09/2026. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman posted at facility A total of five (5) resident files were reviewed. Files contained admission agreements, Physician's Reports, Appraisals, TB clearance, COVID-19 vaccine cards, Functional Capability Assessment, and emergency information. Currently facility has one (2) hospice residents and has waiver for two (2) and has requested additional 3. (continued on (809C) (continued fro 809C) Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily. Incident Medical and Dental: Five (5) centrally stored resident medications were reviewed. Medication is given according to doctor’s orders. Three (3) of (10) resident’s PRN did not have labels on bottles. Medical and dental transportation is provided by family and transportation services. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers but only has 1 relocation site. LIC610 needs to be updated with second relocation site. Residents with Special Health Needs: Facility has recommended documents on residents with home health services and have ongoing communication with home health agencies. No deficiencies were cited today. Technical advisories provided. Exit interview was conducted with staff. A copy of the report, technical advisories and appeal rights were provided.