Routine inspection·November 14, 2025

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced annual inspection visit on 11/14/2025 and was greeted by Administrator Joshua Castillo. LPA Ramirez identified herself and explained the purpose of the visit. The facility is located on a main street and is a two-story dwelling. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be accessible in resident room#207 (R2’s room). Administrator Castillo immediately removed upon LPA Ramirez’s observation. LPA Ramirez observed R5’s bathroom cabinet was unlocked and R5 had direct access to personal grooming and hygiene items. Per R5's recent physician's report, R5 may not have direct access to personal grooming and hygiene items. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected six (6) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside shower. LPA Ramirez observed no-slip coating in showers. See 809-C Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents. Residents Rights-Information: LPA Ramirez did not observe Complaint Poster (PUB 475) in main entrance of facility. LPA Ramirez observed facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted on 10/23/2025. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply located in kitchen pantry. LPA Ramirez observed one (1) evac-chair in each stairwell of the facility. Residents with Special Needs : No large bodies of water were observed LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices were observed to be in working order. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication closet and in bubble packs and/or original containers. LPA Ramirez observed Centrally Stored Medication and Destruction Record. The facility provides incidental medical services. Staffing: Administrator Certificate for Joshua Castillo 05/03/2026. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. see 809-C Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for two (2) out of the two (2) direct care personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for three (3) out of the three (3) personnel record reviewed. Infection Control: Staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for one hundred twenty-five (125) non-ambulatory residents of which twenty (20) may be bedridden. This facility may retain no more than twenty (20) hospice residents. Resident Records/Incident Reports: LPA reviewed resident records for six (6) residents in care. Resident records are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. Two (2) deficiencies were identified, and plan of corrective action was issued. Exit interview conducted. A copy of this report, 809-D and appeals rights were provided.