Routine inspection·October 10, 2025

Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Staff, Bria Sheriff and introduced self and stated purpose of the visit. LPA was informed that there are currently 3 residents in care who are in the facility and 1 resident in rehabilitation. The facility has (5) resident bedrooms, (3) resident bathrooms, living room, dining area, kitchen, pantry, laundry room, backyard, attached garage and side casita with bedroom and bathroom for staff. LPA completed a walk through of facility, review of records and medication audit. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 107 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, fire extinguisher and first aid kit. Posters such as; the personal rights, ombudsman and emergency disaster plans were posted in a common area. There was a designated storage space for resident/staff files. Medications, sharps and chemicals were observed secured and inaccessible to residents. There are no guns, ammunition, swimming pool or bodies of water in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service : Non-perishable and perishable food supply is sufficient for number of residents in care. Dishes, cups, and utensils were also stored properly. Yards/Outside: One shaded patio, a side gate with self-latching handle on the left and right side of the house that leads into the backyard, and a casita with a bedroom and bath for staff. All outdoor pathways were free of obstructions. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medications were audited at random and appeared to not be managed appropriately by staff. LPA observed staff not assisting with medications as needed by transferring medication from its original container, missing initials on MARS after administering, and not obtaining refills on time. Deficiency issued. LPA reviewed the facility's files for emergency disaster plan, infection control plan, liability insurance and emergency drills. LPA observed that the facility did not have emergency kits for the residents in care. Deficiency issued. Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, and appeal rights were discussed and copies were provided to the Licensee, Angela Breedlove who arrived later.