Routine inspection·August 29, 2025

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Kathryn Gabriel. According to the facility’s license, the facility has a maximum capacity for fifty-five (55) residents, of whom all may be ambulatory or non-ambulatory, but none may be bedridden. Per LPA observation, LIC602 Physician’s Reports, and staff interviews: During today’s inspection, there were a total of twenty-two (22) residents in care, and all were ambulatory. The facility’s license does not include endorsements for delayed-egress doors or secured perimeter doors, and neither of these were present. LPA, accompanied by Licensee’s staff, toured the interior and exterior of the facility and inspected all common areas and multiple resident bedrooms. LPA interviewed multiple residents and multiple staff. LPA reviewed care records for multiple residents and personnel records for multiple active staff. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] The facility’s ambient internal temperature was complaint at 72 F. Where tested, hot water temperature at taps accessible to residents were also compliant: Public Restroom #1 Sink was 112.1 F, Public Restroom #2 Sink was 108 F, Laundry Room Sink was 108.9 F, Room C207 Sink was 113.4 F, Room C305 Sink was 107.4 F. and Room C408 Sink was 113.5 F. Appliances to preserve perishable food and medications were also compliant in temperature. There was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were available. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in their original pharmacy packaging, and in locked areas. Confidential records were stored in locked areas. Required licensing postings were observed in visible areas of the facility. Carbon monoxide detectors, smoke detectors, night lights, emergency lighting, and facility telephone were all working. The facility’s fire extinguishers had been serviced within the last twelve (12) months. No fireplaces or pools/bodies of water were observed on the premises. Per the Licensee, no firearms or ammunition are kept at the facility. Fire/disaster drills were performed at required intervals. There were reserve supplies of Personal Protective Equipment (PPE). The five (5) resident files which were randomly selected and reviewed contained required documents. The five (5) employee files which were randomly selected and reviewed contained required documents. Licensee also had proof that the staff met other initial and ongoing training requirements, to include training on the facility's written LIC610E Emergency Disaster Plan and PPE within the last twelve (12) months. No deficiencies were cited during today's annual inspection. However, LPA issued one (1) Technical Violation (TV) regarding updating clients’ Facesheets/Emergency Contact Sheets to include contact information for their respective dentists and any other health providers (the latter as applicable) (refer to the LIC9102-TV page). LPA also issued Technical Assistance (TA) regarding documenting the participation of responsible persons (RPs) at care conferences (refer to the LIC9102-TA page). An exit interview was conducted with Administrator Kathryn Gabriel, to whom a copy of this report, the LIC9102-TV page, the LIC9102-TA page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.