Routine inspection·July 14, 2025

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with Assistant Administrator, Dennise Torres who assisted with visit. LPA explained the reason for the visit. The facility is licensed to serve 136 non-ambulatory residents ages 60 and over, of which 34 may be bedridden. There is a hospice waiver approved for 20 residents. The facility does not have a dementia care plan and does not accept any residents with dementia. There are some residents utilizing home health services but none on hospice. LPA and Assistant Administrator toured the facility which included a random sample of resident rooms along with the kitchen, dining room, activity room, two laundry rooms, storage rooms, 3 offices, Med Room, library and large movie room. The patio area is well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the patio area. Passageways and exits are free of obstruction. The common areas are clean and have the required furniture. The facility has 68 resident rooms with own bathrooms. LPA observed laundry detergent locked in the laundry rooms and inaccessible to residents. Sharps are locked in the kitchen and inaccessible to residents. Randomly chosen resident rooms were toured. Each room has a bed, linen, dresser, light, and sufficient closet space. The resident bathrooms have the required grabs bars and non-skid mat. The water temperature was tested in a random selection of resident bathrooms. The hot water was between 111.5 - 117.1 degrees F which is within the required 105 - 120 degrees F. The kitchen was inspected. LPA observed sufficient food supplies of 2-day perishable and a 7 day of non-perishable food. All the appliances are clean and seem to be operating properly. The smoke detectors are interconnected and there are 2 operable carbon monoxide detectors. The facility has a signal system in place. Fire extinguishers were fully charged and operational. Continue 809C LPA observed the medications are centrally stored in the Med. Room and inaccessible to clients. The facility uses an electronic Medication Administration Record (MAR) log to document medications given. During today’s visit, LPA reviewed resident medications and they are being administered as prescribed by the physician. The first aid kits were observed and found to be in compliance with the Title 22 Regulations. LPA reviewed 5 personnel records and they have the required documents in file. LPA reviewed 5 resident records and they have the following documents in their files such as Admission Agreements, Identification & Emergency Information, Physician's Report with TB test results, Pre-admission appraisal, and Resident rights. Last Fire drill conducted on 07/01/25. Exit interview conducted and a copy of the report was provided to Assistant Administrator.