Routine inspection·May 22, 2025

On 05/22/2025 at 9:10AM , Licensing Program Analysts (LPAs) Renese Howell-Small and Becky Mann arrived unannounced, to conduct the required annual visit to the facility. LPAs met with Executive Director Criselda Espiritu Santo and introduced self and stated the purpose of the visit. The facility is operating as a Residential Care Facility for the Elderly. The total capacity is 240 residents; there are currently 141 residents in care. The facility has a dining area for all residents and adequate seating. LPAs completed a walk through of the interior and exterior facility, review of records and medication(s) audit. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 72 degrees Fahrenheit. LPAs inspected six (6) resident units; they are equipped with the required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPAs inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 117 degrees Fahrenheit. The facility is equipped with carbon monoxide alarms in each of the hallways on both levels, charged fire extinguishers and first aid kit. A third party services both the fire extinguishers and the smoke alarms; last inspection was conducted on 07/12/2024. Postings : Posters such as; the personal rights, emergency disaster plan, CCLD complaint poster and ombudsman were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to residents. There was a designated storage space for resident/staff files. Medications were observed to be locked, inaccessible to residents in the medications room on the first level. There is no swimming pool, firearms or ammunition 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 residents in care. Dishes, cups, and utensils were also stored properly. Kitchen staff have ServSafe certification on file. Yards/Outside: The facility has several shaded areas and courtyards in the back of the facility. LPAs observed three (3) storage units in the parking lot of the facility. Record Review: LPAs reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, training(s), and health screenings. LPAs also reviewed six (6) resident files for admission agreements, updated physician reports, and needs and services plans. One deficiency was cited, a Technical Violation and Technical Assistance was given during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102 and Appeal Rights were discussed and copies were provided to Executive Director, Criselda Espiritu Santo.