Routine inspection·July 10, 2025

On July 10, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry into the facility by care giving staff after explaining the purpose for the visit. Administrator (AD) Lisa Roche was notified via telephone and later arrived to assist with the inspection. LPA observed that Lisa Roche has a valid Administrator certificate which expires on July 15, 2026. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents and has a hospice waiver for six. The facility is a single story home with six resident bedrooms, three shared resident bathrooms, a living room, a dining room, a kitchen, a storage room, and an attached three car garage. LPA, accompanied by the AD, conducted a tour of the interior portions of the facility. On today's visit, LPA observed two resident in care and two care giving staff present. LPA observed the resident eating breakfast in the dining room which consisted oatmeal, waffles, juice, and coffee. LPA observed the See Something, Say Something poster, (PUB 475) mounted on the wall by the dining room. LPA inspected all six resident bedrooms and observed them to be free of hazards. LPA observed resident bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA observed additional linens to be stored in a hallway closet. LPA inspected the three shared resident bathrooms and observed them to be clean. Bathrooms were equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 132.6 and 133.3 degrees Fahrenheit. LPA observed the facility has a two day perishable and a seven day nonperishable food supply on hand in the kitchen. LPA observed kitchen appliances to be clean and operational. CONTINUED ON 809-C LPA observed the five burner gas stove lights unassisted. LPA observed kitchen knives and sharps to be stored in a locked kitchen cabinet. LPA observed chemicals and toxins to be stored in a locked kitchen cabinet under the sink. LPA observed fire extinguishers to be mounted on the wall in the resident hallways, in the kitchen, and in the three car garage. LPA observed fire extinguishers to be charged and serviced as of August 28, 2024. LPA tested the wired smoke detectors/carbon monoxide detectors which tested operational. LPA observed the facility does not have any emergency disaster drills documented. LPA observed the centrally stored medication to be kept in a locked cabinet located in the kitchen. LPA observed the facility has a First Aid Kit stored in a hallway cabinet and it had all the required components. LPA observed the door leading to the attached three car garage and storage room to be kept locked and inaccessible to residents in care. LPA observed the garage to be used for storage and laundry. LPA observed chemicals and toxins to be stored in a locked cabinet in the garage. LPA observed the facility has a three day emergency food and water supply stored in the garage. LPA observed the storage room to be used for storage and to be free of any hazards. LPA, accompanied by the AD, conducted a tour of the exterior portion of the facility. The exterior portion was observed to be free of hazards and obstructions. LPA observed a shaded outdoor seating area with furniture for resident use. LPA observed the perimeter gates of the facility to be self latching and can be opened in an evacuation. There are no bodies of water on the premises. LPA reviewed all three resident files. All the required documentation were present and current in the resident file reviewed. LPA reviewed the residents' medication and medication records. LPA reviewed three staff files. All staff are background cleared and associated to the facility. Based on the observations made during today's visit, a deficiency is being cited on the attached LIC809-D. An exit interview was conducted with Administrator Lisa Roche. A copy of the report and Appeal Rights were provided.