Routine inspection·October 23, 2025

Licensing Program Analyst (LPA) Vaid conducted an announced annual inspection. LPA was allowed entry by Marilyn Figueroa-DSP, informed Tiffany Vander Poorten, administrator/licensee who arrived shortly after and assisted with the inspection. The capacity is six (6). Facility has an approved Dementia Care Plan. Hospice waiver is approved for six (6). Currently five (5) residents are residing. The property is a single-family residence located in a neighborhood, consisting of four (4) bedrooms, two (2) full bathrooms, one (1) half bathroom, kitchen, dining room/living room with TV, laundry room, family room, administrator office, kitchen, and detached garage. Passageways, walkways and patios are free from obstructions. The entrance and side areas are free of hazards and debris. Garage is not accessible to residents. Fire clearance was granted for six (6) non-ambulatory and zero (0) bedridden. Fire clearance and Dementia care plan are in place. Auditory devices are installed at all exits and operable. Bedroom#1 and #2 are approved for one (1) non- ambulatory in each room. Bedrooms #3 and #4 are approved for two (2) non- ambulatory in each room. Garage is not approved for residents or staff residence. Bedrooms have nightstand, adequate lighting, adequate closet and drawer space. Bedrooms are spacious and allow for easy passage between and comfortable for usage. Toilet, wash basin, bathtub/shower in bathrooms are operable. Bedrooms are accommodated for residents. Grab bars are maintained for each toilet, bathtub and shower. Adequate supply of linen, wash clothes and towels are observed. Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet in the kitchen and inaccessible to residents. Food supply consist of two days of perishable and two weeks of non-perishable was observed. Continued on 809C..... Medication cabinet is installed with a lock and inaccessible to residents. First aid kit has required items. First Aid manual from American red cross was available for staff use and inaccessible to residents. Dual Smoke /carbon monoxide detectors are tested and operable. They are located in hallways and each bedroom. Poisons, toxins, and cleaning supplies are locked and inaccessible to residents. They are stored separately from food source. Outdoor activity area is furnished with chairs and table and in compliance. Locked cabinets for records of staff and residents are installed and available. Residents file are observed Water Tested at 117.6 degrees Fahrenheit. Menus are available for review. Free landline telephone is available for residents’ use and operable. Fire extinguishers are available in the facility. They are fully charged. Exit conference was conducted, copy of this report was provided to Licensee Tiffany Vander Poorten. Technical Violation regarding proper recording of medications was provided and discussed. Licensee will update the Medication administered record, provide proof for five residents Medication Administered Record.