Routine inspection·March 24, 2026

On 3/24/26, Licensing Program Analyst (LPA) Kyle Wellington made an unannounced visit to the facility to conduct an annual inspection. LPA was greeted at the door by the Administrator (Admin), Monina Arjona, who was informed of the purpose of the visit. LPA observed three (3) staff and six (6) residents present at the facility. The census at the facility is six (6) residents. LPA was informed that one (1) resident is currently receiving hospice services at the facility. LPA received a resident roster from the Admin. LPA toured the inside and outside of the facility with the Admin. LPA conducted an observation, interviews and record reviews at the facility for the inspection. Facility Overview: The facility is a one story house with five (5) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, kitchen, family room, dining room, laundry room and attached garage. There are no pools, bodies of water or firearms at the facility. The facility has a fire clearance to serve six (6) non ambulatory residents. The facility has an approved hospice waiver for one (1) resident. Infection Control: LPA observed soap dispensers in the bathrooms and hand sanitizers in the facility. Cleaning supplies were locked in the laundry room and available for regular facility maintenance. LPA reviewed the facility’s infection control plan which met the department’s requirements. Physical Plant: LPA observed the inside and outside of the facility to be clean, safe and well kept. The floors, windows and doors were clean and well maintained. The family room and dining room furniture was in good repair. The halls had night lights and were free of obstruction. The residents’ bedrooms were neat, organized and had the required bedding, furniture and lighting. Bathrooms were clean, sanitary and contained paper towels, grab bars and non-slip tile in the showers. The hot water temperature in the bathroom was measured at 107.2 F. Clean linens and towels were available in cabinets in the hall. Laundry equipment appeared to be in good working condition. The two (2) fire extinguishers were charged and available for use. Facility had smoke and carbon monoxide detectors and LPA found them to be battery operated and operational. Facility had a pull system fire alarm connected to emergency lights at three (3) exits. The backyard was clean, free of hazards and contained outdoor furniture and shaded area for the residents. Kitchen/Food Service: LPA observed the kitchen to be clean, organized, and well maintained. The kitchen had the ability to prepare and store food in a safe and clean environment. Kitchen equipment appeared to be in good working condition. Dishes, containers, pot/pans and silverware appeared clean and in good condition. All sharp and dangerous objects were kept in a locked cabinet under the sink inaccessible to residents. Cleaning supplies were kept in a locked cabinet under the sink inaccessible to residents. The refrigerator/freezer was clean, stocked and at the required temperatures. Food in the refrigerator/freezer and pantry/cabinets/garage were properly stores and not expired. The facility has at least a two day supply of perishable foods and a seven day supply of non perishable foods. The hot water temperature in the kitchen was measured at 105.8 F. Care & Supervision: LPA observed the facility had sufficient staff present to supervise the residents. Administration: LPA observed that facility sketch, emergency phone numbers, Long Term Care Ombudsman contact information, residents' personal rights information and complaint procedures were posted in the hall. Liability insurance was up to date and expires on 6/22/26. Admin holds a current Administrator Certificate and a current CPR Certification. Admin has a criminal record clearance. Record Review and Resident/Staff Files: LPA compared the staff present at the facility and on the staff roster to the Guardian staff roster for criminal record clearance. LPA reviewed the records of two (2) staff files and three (3) residents’ files. The files contained all the required documentation and paperwork. The staff and residents’ files were kept in a locked cabinet near the dining room inaccessible to unauthorized individuals. Health Related Services/Incidental Medical Services: LPA observed all residents’ medications were locked in a cabinet near the dining room inaccessible to residents. No medication was stored in a refrigerator with food items. LPA reviewed three (3) resident’s medication to the facility’s medication log to make sure all medication was accounted for and dispensed correctly. First Aid kit contained all the required items and was kept in a hall and on a desk near the dining room. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan. The plan was current and up to date. Safety and fire drills have been conducted with the last drill occurring on 3/8/26. LPA observed all facility exits were clear of obstructions and had the required signage. No deficiencies were cited during this visit. Exit interview was conducted with the Administrator and a copy of this report was given to the Administrator.