Routine inspection·August 14, 2025

Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Staff, Mayanne Matias and introduced self and stated purpose of the visit. LPA was informed that there are currently 5 residents in care who are in the facility. The facility has 6 bedrooms, 3 bathrooms, kitchen, dining area, living room, office area, laundry room, pantry room, attached garage, and backyard with a shed. LPA completed a walk through of facility, and review of records. 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 72 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 120 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 CCL complaint poster were posted in a common area. There was a designated storage space for resident/staff files and medication. There is no swimming pool, bodies of water, guns or ammunition in the facility. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. 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. Facility has a wide variety of food available for residents. 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 1 shed used for storage. 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 observed two nonambulatory residents accomodated in ambulatory approved bedrooms. Deficiency issued. LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA audited medication at random and appeared to be dispensed appropriately. LPA reviewed the facility's infection control plan, and emergency drills. LPA observed that the facility did not have proof of liability insurance. Deficiency issued. LPA observed that the facility did not have an emergency disaster plan. 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 Administrator, Cristina Duarte who later arrived.