Health check·February 3, 2026

Licensing Program Analysts (LPAs) Pang Lee and Shakaricka Hughes arrived unannounced to conduct a health and safety inspection and a case management visit. The facility is on a quarterly visit due to non-compliance concerns discussed during a Zoom meeting on 11/18/2025. LPAs met with care staff Misivono Qadroka and explained the purpose of the visit. Care staff informed Administrator Aliti Waqalala via text message that Community Care Licensing Division (CCLD) was present at the facility; however, the Administrator did not respond. LPA Lee attempted to contact Administrator Waqalala by phone and left a voicemail. The facility census was nine (9) residents with two (2) staff present. The purpose of today’s visit was to conduct a quarterly inspection. LPAs followed up on the following areas: · Incontinence care: LPAs did not observe or detect any incontinence odors throughout the facility. · Criminal record clearance and staff association requirements: LPAs observed Staff 2 (S2), who is fingerprint-cleared and associated with the facility. · Fire clearance and fire safety: LPAs observed that the front gate was unlocked and easily operable. Exit doors and emergency exits were observed to allow single-action operation, and residents were not locked in or out of the facility. CONTINUED LIC 809-C · Incidental medical and dental care services: LPAs reviewed Resident 1 (R1)’s Medication Administration Record (MAR) and observed missing initials for medication administration on 02/01/2026 and 02/02/2026. LPAs reviewed R1’s medication, Amlodipine 10 mg (take one tablet by mouth daily), with a quantity of 30 tablets. A review of the Centrally Stored Medication Destruction Record (CSMDR) showed a start date of 11/05/2025. Care staff Qadroka conducted a pill count and reported ten (10) tablets on hand, indicating discrepancies in R1’s medication count. · Food supplies: LPAs observed that the facility had sufficient food supplies, meeting the requirements of a two-day perishable and seven-day non-perishable supply at the time of the visit. · Change in condition assessments and reassessments: LPAs learned that Resident 2 (R2) was sent to the hospital on 10/22/2025 and discharged with a special mechanical-soft diet. A review of R2’s LIC 603A (Resident Appraisal) and LIC 625 (Needs and Services Plan) indicated that the special diet was not updated to reflect this change in condition. · Door alarms and alert systems: LPAs observed door alarms installed on the front door, dining room sliding door, and the back door of Resident Room #3. · Quality of food provided: LPAs observed seven (7) residents seated at the dining table eating breakfast. The meal included egg omelets, hash browns, toast, strawberries, blueberries, bananas, and coffee. LPAs also observed apples and oranges available on the kitchen counter for resident access. · Personal rights: LPAs toured the kitchen and observed that the refrigerator and food cabinets were unlocked, allowing residents access in accordance with personal rights requirements. · Communication and responsiveness with the Department: LPA Lee emailed Administrator Waqalala on 01/29/2025 requesting additional information and documents related to complaint control number 27-AS-20251231102322, with a due date of 01/30/2025. A follow-up request was also sent on 02/01/2026, with no reply from the Administrator. During today’s visit, care staff Qadroka and LPA Lee were unable to reach Administrator Waqalala. As a result, of today's quarterly visit, deficiencies can be found on the 809D page. An exit was conducted, and a copy of the 809 report, 809D pages, was provided to care staff Qadroka