Routine inspection·November 20, 2025

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced annual inspection visit on 11/20/2025 and was greeted by Caregiver Melinda Nofuente. LPA Ramirez identified herself and explained the purpose of the visit. The facility is located on a residential street and is a single-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 inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) 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. LPA Ramirez observed seated shower chairs in bathrooms. 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). see 809-C Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. 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 10/01/2025 and 11/01/2025. 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 garage. 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 garage 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. During inspection, LPA Ramirez observed that R1 and R6 share a room. During record review of R6's resident records, LPA Ramirez did not observe a statement signed by R6's indicating their acknowledgment that their roommate intends to receive hospice care in the facility and their voluntary agreement to grant access to the shared living space to hospice caregivers and others. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication closet and in bubble packs and/or original containers. During the inspection of kitchen area, two (2) of R1's medications were observed stored adjacent to perishable food items, posing a potential risk to resident safety and highlighting a deficiency in medication storage protocols. During inspection of additional perishable foods located in accessible and unlocked garage, one (1) of R2's discontinued medication and R7's discontinued medication were observed stored adjacent to perishable food items, posing a potential risk to resident safety and highlighting a deficiency in medication destruction protocols. Staff interviews and records reviewed revealed R7’s services were terminated in 2024. Staff interviews revealed that R2 was removed from hospice on 10/15/2025, and the medication observed in garage fridge was discontinued by their doctor. LPA Ramirez observed Centrally Stored Medication and Destruction Record for six (6) out of the six (6) residents in care. The facility provides incidental medical services. Staffing: Administrator Certificate for Judy Ragno with an expiration date of 11/09/2027. 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) personnel record 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 five (5) non ambulatory residents and one (1) bedridden resident over the age of 59 years old. This facility may retain no more than six (6) hospice residents. There was one (1) resident on hospice during time of inspection. 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. Three (3) deficiencies were observed and cited during this annual inspection. Exit interview was conducted with Administrator Judy Ragno via telephone. A copy of this report, 809-D and appeals rights was provided via email due to printer out of ink.