Routine inspection·August 25, 2025

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Glenda Precillas and explained the reason for the visit. Licensee arrived shortly after. The facility is licensed to serve 6 residents age 60 and over of which 6 may be non-ambulatory with a hospice waiver for 6. The facility is located in a residential area and consist of a single home with (4) resident bedrooms, (3) bathrooms, a living room, a dining room, a kitchen, a family room, an attached garage/laundry, a front yard, and a back yard. The following domains were reviewed during this visit: Infection Control : Facility maintains a copy of the infection control plan. Staff #2-4's medical assessments did not have results for TB test. Operational Requirements: Facility maintains a plan of operation, fire clearance. Facility is operating within the limitations of their license. They currently don't any residents under hospice care, or bedridden. A current liability insurance was observed and a copy was obtained. Physical Plant/Environmental Safety: LPA toured the facility with Glenda Precillas and observed the following. Facility was observed clean and in good repair. Living room, dining room, and family room were observed with furniture in good repair. Living room has a covered fireplace. Kitchen was observed clean. Cleaning supplies and sharps are maintained locked under the sink. Refrigerator/freezer and pantry were observed. Medication cabinet is located in family room. Four (4) resident rooms were observed with sufficient lighting, required furniture and bedding supplies. Half bed rails were observed in residents' beds and physician's orders were on each residents' file. Three (3) bathrooms were observed in good repair and clean Water temperature was tested in each bathroom sink and tested at 105.3 degrees F., which is within the required 105-120 degrees F. Oxygen tanks were observed in bedroom #3, no smoking sign was not observed. A fire extinguisher was observed. Carbon Monoxide/Smoke detectors were tested and are in working condition. Laundry area was observed in good repair. Two large bodies of water were observed, a pool and a pond. The pool has a 5ft fence surrounding it and the pond has a screen covering it. Passageways were clear of obstructions. Staffing: Administrator certificate was reviewed for Josiah Poorten #7020881740 exp. date: 11/11/25. CPR/First aid training was observed for staff. Staff is on duty during the night shift. Personnel Records/Staff Training: LPA reviewed 5 staff files. Files were available for review. Files include; health screening, background clearance, personnel record, and training for each staff. Two staff were interviewed. Resident Rights/Information: License, Let us Know (PUB 475), Ombudsman, personal rights posters were posted in the family room. Planned Activities: Facility provides activities such as puzzles, books, board games, music entertainer. Food Services: LPA observed at least 2 days of perishables and 7 days of non- perishable food supplies. An additional refrigerator was observed in the garage. Kitchen was observed clean and free of pest. Incidental Medical and Dental: Facility provides assistance with medical/dental arrangements and with medication assistance. Medications were observed stored in locked medication closet. LPA reviewed medication for 5 residents. Resident Records/Incident Reports: LPA reviewed 5 residents files, each contained admission agreement, medical assessment, TB clearance, pre-appraisal, and appraisal. Two resident were interviewed. Disaster Preparedness: LPA reviewed emergency disaster plan LIC 610E(3/19) last reviewed on 7/14/25. Emergency drills are conducted quarterly, last emergency drill was conducted on 7/14/25. Residents with Special Health Needs: Facility is not serving residents with Special Health Needs. Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Glenda Precillas and a copy of this report, LIC 809D, and appeal rights were provided.