Routine inspection·October 16, 2025

Unannounced Annual visit made out to this facility on 10/16/2025 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility staff persons, Kaye Elma and Joan Dickens, who were briefly interviewed at this time. This LPA requested that the facility staff go ahead and contact the facility designated Administrator to inform her that CCL was present at this time. Current census was 5 residents. It was learned that there were (2) residents under the care of hospice at this time. This facility does have an approved waiver to be able to accept and retain up to (5) residents under the care of hospice at any given time. It was learned that this facility has a program to be able to accept and retain dementia residents at any given time. It was learned that there were (2) residents diagnosed with dementia at this time. It was learned that there was (1) resident receiving services through home health at this time. Tour of this facility was conducted. Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Linen closet, located in facility hallway closet, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time. Kitchen area was toured. Kitchen drawers and cabinets were opened and reviewed. Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times. Pantry area was toured. Additional food storage units located in the garage area were observed to be present and functional at this time. Laundry area, located in the room next to the garage, was toured. Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Administrator certificate, # 6066497740, for Cecil de Lara was observed to have an expiration date of 03/21/2027 and in compliance at this time. Medication cabinet, located in the facility kitchen cabinet , was observed to be locked and made inaccessible to the residents at this time. First aid kit, located in the medication cabinet, was reviewed. This LPA observed that it did contain all of the required components at this time. Fire extinguishers were located throughout this facility and observed to have been annually inspected by the local fire extinguisher company, Joegensen & Co Fire Extinguisher Company, with the inspection date of 04/04/2025 and in compliance at this time. Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees. A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted. A review of (5) facility personnel records was conducted on the LIC 859. A review of (6) facility resident records was conducted on the LIC 858. The following forms and documents were requested to be updated and submitted into CCL for review by this LPA: LIC 308 LIC 400 LIC 500 LIC 610 There were no deficiencies observed or cited during today's annual visit. Exit Interview