Routine inspection·August 21, 2025

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of conducting the Required 1-Year annual evaluation using the Care Inspection Tool. LPA was greeted and granted entry by Administrator (Admin) Jennifer Perez and explained the reason for the visit. Administrator provided proof of administrator's course work which completed on June 25, 2025. The facility is a single story structure and is licensed to provide services for age range 60 and over for six non-ambulatory residents. A waiver was granted to provide hospice services to two residents at one time. During today's visit, there are six residents in care of which one is under hospice and two staff on duty. LPA toured the physical plant with Admin Perez. Facility is clean and sanitary. LPA observed four resident bedrooms and two resident bathrooms. Resident bedrooms had all required furnishings. Bathrooms were found to be in compliance, clean, and operational. The hot water temperature measured at 108.6 and 107.4 degrees Fahrenheit in the resident bathrooms. All common areas were inspected including the detached two car garage. The swimming pool gate is secured and the fire place is properly screened. LPA reviewed the Emergency Disaster Plan (LIC610E) and observed sufficient emergency food and water in the garage. The 610E was not reviewed annually and the emergency drills were not conducted quarterly. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed sufficient two-day supply of perishables and seven-day supply of non-perishable food. LPA toured the exterior portion of the facility. The outdoor passageway is free of obstruction, the exit gates are operational, and there were sufficient seating and shading. The fire extinguisher was purchased on August 21, 2025 as verified per the purchase receipt. The auditory devices and smoke/carbon monoxide detectors were tested and operational. The Complaint Poster, 'See Something, Say Something,' (PUB 475) was available and posted in the correct size. LPA conducted a review of all resident/staff files. Discrepancy noted with resident files as five out of six residents did not have a current reappraisal. Two out of two staff are not CPR/First Aid certified and did not complete their annual 20 hour training for this year. Medications were audited in six out out of six residents. Discrepancies noted in two out of six residents as medications were not administered as prescribed. An interview was conducted with one resident due to insufficient time. LPA discussed the following areas: to ensure reappraisals for all residents are completed as frequently as necessary or annually, medications are administered as prescribed, to ensure at least one staff per shift is CPR/First Aid certified, to ensure staff are receiving their 20 hour annual training, to conduct quarterly emergency drills per shift, to review the LIC610E annually and update as necessary, and to ensure timely payments of the annual licensing fee due on August 24, 2025. Based on the observations made during today's visit, deficiencies are being cited, and Technical Violations are also being issued. An exit interview was conducted with Administrator Jennifer Perez, and a copy of this report was provided at exit.