Routine inspection·May 12, 2026

On 5/12/2026, Licensing Program Analyst (LPA) Ahliah Sharp conducted an unannounced required annual visit. LPA met with Executive Director Robyn Icamen who was informed of the purpose of the visit. The facility’s current census is 49, with approval for fifty-eight (58) ambulatory, fifteen (15) non-ambulatory, one (1) bedridden resident; and a hospice waiver approved for eight (8) residents. LPA conducted a tour of the interior and exterior of the facility, reviewed facility documents and conducted five interviews; two (2) staff and three (3)residents. LPA observed the following: LPA observed the physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good working conditions. The outdoor area was observed to be free of any hazards. LPA observed a courtyard with outdoor furniture and shaded area for residents. Facility kitchen had the ability to prepare food in a clean environment and possessed equipment in good working conditions. The sharp and dangerous objects were observed to be inaccessible to residents in the kitchen. Facility kitchen receives one shipment of food every week, ordered on Monday and arrives on Tuesday. LPA observed the facility sketch, exit routes, personal rights, complaint information and emergency phone numbers posted around the facility. The smoke detectors and carbon monoxide detectors were operational. LPA observed the facility exceeded the required two (2) day supply of perishable and seven (7) day supply of non-perishable foods. LPA conducted medication review with staff, and observed the medical sharps stored in locked boxes inaccessible to residents in care. Continued on LIC809C Continued from LIC809... Staff files review included, but are not limited to, personnel records, criminal record clearance, required training, and valid first aid/CPR certification. The employee health screenings had been removed when the new company took over. They were advised that they would need to be made available in the employee files. Resident files included but are not limited to signed admission agreements, pre-placement, personal rights, needs and service plans, and updated physician reports. LPA reviewed the facility's emergency and disaster plan. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies and first aid kit with all required items. Facility contained multiple charged fire extinguishers last serviced in March 2026, and Fire and Earthquake drills were last conducted on April 15, 2026. LPA observed all six (6) of the thermostat temperatures ranging from 75-78 degrees F. LPA advised ED about the water temperature needing to be a little warmer even though the resident was comfortable with the current temperature of 99.9F and the access to the health screenings of the staff need to be placed back in the staff files. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to ED Robyn.