Routine inspection·November 17, 2025

At approximately 10:00 AM, Licensing Program Analysts (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and met with Shanti Ragland, Administrator. Facility is a Residential Care Facility for the Elderly (RCFE) with thirty (30) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for eleven (11), with five (5) Hospice residents currently in care, and is approved for forty-four (44) non-ambulatory residents and ten (10) bedridden resident. At approximately 10:30 AM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a one story building, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured between 95.3 degrees F and 139.6 degrees F. LPA informed Administrator that the allowable range is 105 to 120 degrees F per Title 22 regulations. Facility has four (4) separate water heaters and water temperatures vary greatly between faucets closer to each water heater and those further away. Administrator had staff turn up two water heaters where water temperatures tested below the allowable range, and Administrator agreed to post hot water warning signs at every faucet in the facility that tests above the allowable range in order to bring the facility into compliance with regulation. 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. Cabinets containing cleaning supplies and other items that could pose a risk were locked. 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 courtyard with outdoor space for activities. LPA observed residents engaged in morning exercises and later engaged in crafting activities. Facility has a monthly activity calendar posted with several activities planned each day. Continued on LIC809-C... Continued from LIC809... LPA observed a supply of puzzles, games, and crafting supplies available for residents in care. Facility has internet access and Administrator agrees to ensure an internet access device is designated for resident use. Facility telephone was tested an operational during inspection. Facility has several fire extinguishers which were observed charged and were last serviced 07/2025. Facility passed their last fire system inspection and testing conducted by a third party vendor 09/2025. Facility conducts quarterly disaster drills with the last one completed on 10/2025. LPA observed the facility's infection control plan, first aid kit, PPE, flashlights, and emergency supplies. LPA observed a solar panel system and generator for emergency preparedness. LPA reviewed facility's emergency disaster plan which was last updated 05/2024. At approximately 12:30 PM, LPA conducted file review. LPA reviewed five (5) staff and five (5) resident files and observed the following: five (5) of five (5) staff files reviewed contained the required paperwork including proof of current FA/CPR per regulation. Five (5) of five (5) staff files reviewed were short two (2) hours of Hospice, postural supports, and/or restricted health conditions training. Administrator has scheduled an all staff training for this Friday to ensure facility is brought back into compliance immediately. Five (5) of five (5) resident files reviewed contained the required paperwork per regulation. At approximately 3:00 PM, LPA reviewed medications and medication records which are maintained and stored in compliance with regulation. Administrator states that the residents families coordinate residents' medical and dental appointments and transportation to and from visits. However, facility will assist with coordinating these appointments and transportation for residents upon request. Facility does not manage P&I. Updated copies of the following documents are to be submitted to CCL within 30 days of this visit : -LIC610E - Emergency Disaster Plan (updated) -LIC500 Personnel Report (updated) No deficiencies were cited during today's inspection. Exit interview conducted with Administrator, whose signature on form confirms receipt.