Routine inspection·March 14, 2025

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual and met with Rose Mead, Administrator. Caregivers Rowena Tirasol and Gina Willard were also present and maintenance staff, Thaddeus Tirasol. LPA observed (2) resident in the common areas, (1) resident in their rooms, and (1) resident was currently out of the facility with a family member. The facility is licensed for (5) non-ambulatory residents (1) of whom may be bedridden, (1) ambulatory and has a hospice waiver for (3). Currently, there are no residents on hospice. LPA and Administrator toured the interior/exterior of the facility including the common areas, (4) private resident bedrooms, (1) shared resident bedroom, (2) resident bathrooms, (1) staff room, kitchen and laundry area, and office area. LPA observed the facility to be clean, in good repair and odor-free. Bathrooms have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters. There is sufficient 2+ day perishable and 7+ day non-perishable supply of food. Sharps, medications and toxins are locked in the kitchen/laundry area. The inside temperature measured 71*F. Hot water temperature measured 120*F in a resident bathroom. Smoke/monoxide alarms are working and the extinguisher was last serviced 3/28/24- to be serviced again by 3/28/25. There are sufficient linens/towels/blankets and PPE (gloves, masks and washable gowns). All exit doors have auditory devices. LPA observed (2) unlocked gates from the outside patio and covered patio seating. There are no pools. Discussed PIN 24-09 and updates to Adm Agreement. LPA reviewed (2) resident files - files were organized with current physician's reports and care plans. Medications were reviewed for (2) residents- orders matched medications being administered and documentation is maintained. (3) staff files were reviewed Staff have completed the required annual/initial training. All staff have current First Aid/CPR certifications and are cleared/associated or requested to be associated. RCFE Administrator certificate #7004149740- exp 3/18/26. LPA reviewed the updated Dementia Care Plan (dated 2/18/25). An updated copy of the LIC308, LIC500 and current liability insurance due by 3/21/25. There are no deficiencies issued. Exit interview. Copy of report provided.