Routine inspection·September 16, 2025

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 9/16/25 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator arrived to assist LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA reviewed (4 ) resident and ( 2) staff files. Resident file deficiency noted, staff training documentation discussed relative to PIN 23-16- ASC and regulation updates 2025.. LPA requested the following documents to update the facility file: Liability insurance, Room 3 door building permit, Administrator designation and Certificate. As a result of this visit, The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Exit interview conducted with Samantha and copy of report (and appeal rights) left at the facility.