Routine inspection·April 29, 2026

At approximately 10:45 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and met with Emeshell Docejo, Designated Responsible Party (DRP). Facility is a Residential Care Facility for the Elderly (RCFE) with five (5) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for one (1), and is approved for six (6) residents. At approximately 11:45 AM, LPA initiated a tour of the facility with DRP and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in regulations. LPA observed two instances of cleaning chemicals accessible to residents in care. DRP secured the the items away from residents immediately and agreed to ensure that all cabinets containing cleaning supplies and other items that could pose a risk to residents in care would remain secured at all times. Facility has at least two days of perishable and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a shaded seating area in the front and backyards with outdoor space for visiting and activities. LPA observed a locked shed and a locked storage container in the backyard which contained care equipment, tools, and chemicals. LPA also observed a newly built fence securing the area of the property where two trailers are located and used for staff living quarters. Facility has internet service and an internet access device available for resident use as required per regulation. Continued on LIC809C... Continued from LIC809... Residents were observed engaging with staff and visitors, reading, and watching TV during inspection. LPA observed supplies for other activities. Facility's fire extinguisher was observed fully charged and the tag indicates it was last serviced 10/2024. DRP states the fire department inspected it within the last year and agrees to follow up on getting it re-tagged with the most recent inspection date. Smoke and Carbon Monoxide detectors were tested and operational during inspection. DRP states the facility conducts bi-weekly disaster drills, but facility log indicates the last drill was conducted 01/2026. LPA informed DRP that drills shall be conducted and logged no less than quarterly. DRP agrees to bring the facility into compliance immediately. LPA observed the facility's infection control plan, first aid kit, PPE, and emergency supplies for emergency preparedness. LPA reviewed facility's emergency disaster plan and DRP agrees to submit an updated plan to the Department. Facility has a back up generator for emergency preparedness. At approximately 2:00 PM, LPA reviewed five (5) resident records. Five (5) of five (5) residents' records contained the required documentation. DRP agrees to ensure that the correct LIC613 personal rights form is on file for each resident, specifically the LIC613C form for residential care facilities for the elderly. At approximately 3:00 PM, LPA reviewed four (4) staff records. Four (4) of four (4) staff records reviewed contained all the required paperwork including the required training hours and current CPR and first aid certificates. At approximately 4:00 PM, medications and medication records were reviewed and were observed managed and stored in compliance with regulation. DRP states that most of the residents' family members coordinate residents' medical and dental appointments and transportation to and from visits. However, facility assists with coordinating appointment and third party transportation when needed. Facility does not handle P&I. DRP provided LPA with proof of liability insurance. Continued on LIC809C... Continued from LIC809C... Updated copies of the following documents are to be submitted to CCL within 30 days of this visit : LIC500 Personnel Report (updated) LIC610E Emergency Disaster Plan (updated) No deficiencies cited during today's inspection. Exit interview conducted with DRP whose signature on for confirms receipt of documents.