Routine inspection·February 19, 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 by Staff, Raquel Jimenez. Administrator, Flora Kelly arrived during the visit. LPA, accompanied by administrator, toured the interior and exterior of the facility, and inspected each room. 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 in working order. Extra linens and hygiene supplies were present. However the facility did not have 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 107 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. No pools or bodies of water were observed on the premises. Per the administrator, 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. Some residents did not have current Resident Appraisals, which were dated back to 01/2025. Resident #4 does not have TB test results. Continued on LIC 809C. The Emergency Disaster Plan was not updated and training was last conducted in 2022. The administrator was advised Staff #1, currently working today at the facility has a fingerprint clearance but is not associated to the facility. Also, there was no staff file for Staff #1. Portable heaters with red coils were observed in the facility, which poses a danger to their residents with dementia. The administrator removed them and stated they will purchase new ones without hot red coils. There was a gap in the window located in the kitchen area due to an air conditioning unit inserted into the window. Other windows with air conditioners have cardboard on the outside of the window to fulfill the gaps. However, due to current rain the cardboard's have water damage. A better seal is needed for the windows with the air conditioners. The administrator was advised of the new Dementia laws and the requirement of the updated dementia plan of operation. Deficiencies were observed or cited during today's annual inspection. Also, Advisory Notes were issued, along with a civil penalty. 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.