Routine inspection·February 25, 2026

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility and conducted the visit with Staff, Raquel Jimenez. LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, but needed some repair. During the inspection of food items in the fridge/freezer, once the door was opened there were some wires sticking out from the bottom. The main bathroom's shower used by the residents had rust. Also, one of the sink cabinet door's doesn't open and the other door looked like rotting wood at the bottom. The garage door lock is broken, which contains the laundry room. However, there is no access from the house to the garage. The sun room has large hanging piece of ripped screen. The locked shed located in the backyard has so many items that the storage has buckled and the side opened up, allowing an opening/access from the side. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents were all compliant and measured at 118 F.. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to residents. Medications were labeled, as required, and stored in locked areas. Continued on LIC 809C. No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records/files. The disaster drill was not readily available at the facility. However, staff confirm they attend the training. The Resident Appraisals were not updated annually for two residents. The Physician Reports for three residents were incomplete and/or inaccurate. Confidential records were stored in locked areas. A deficiency was observed and cited during today's annual inspection. Advisory Notes were also issued. An exit interview was conducted with Staff, Raquel Jimenez to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.