Routine inspection·October 17, 2025

Licensing Program Analyst (LPA) De Leon arrived at facility for an unannounced annual inspection visit. LPA met with Administrator Brenda Victoria and explained the purpose of the visit. LPA toured the inside and outside of the facility with Administrator the following was noted: Infection Control: The facility has an infection control plan on file. The facility is clean, safe and sanitary. The facility trains staff initially upon hiring and annually thereafter on infection control and PPE. The facility has about a 30-day supply of PPE on hand. The facility has a book to sign in an out for visitors at the facility and hand sanitizer is present. Operational Requirements: The facility is in compliance with the granted fire clearance. The facility is licensed for a capacity of 6, 5 of which can be non-ambulatory residents. The facility has an approved hospice waiver for 5. Physical Plant & Environmental Safety: The facility is a 5 bedroom and 2 bathroom home currently occupying 6 residents. The facility has smoke detectors and 1 carbon monoxide monitor. The lighting and lamps in resident rooms are sufficient for the use of the facility and for resident’s comfort. The facility kitchen is clean, safe, and sanitary. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are locked in laundry room and under the kitchen sink. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard for client use with plenty of shade. The facility has telephone and internet service for resident use. The facility has fencing around the back yard with a self closing and self latching gate. Continued 809-C Staffing: The facility has 11 staff and 1 administrator. Five staff files were reviewed for Health screening with TB results, Applications, fingerprint clearances, and First Aid and CPR certificates, all forms were legible and up to date. Personnel Records and Staff Training: The facility keeps staff files confidentially in the locked staff office. The facility administrator certificate expires on 03/20/2026. Five staff files were reviewed for initial and annual training requirements some staff are not meeting the hours or the subject matter requirements. Residents Rights/Information: Required postings were posted in the common area of the facility, Personal Rights, Persons with disabilities, CCL Complaint poster, License, rights to resident/family councils, Non-Discrimination notice, and visiting policy hours. Internet is provided to each client and each client is given confidentiality and privacy. Planned Activities: Four of the residents attend Day programs. The facility offers games, puzzles, arts and crafts, discussions, magazines, outings and walking. Food Service: The facility provides 3 meals and snack daily to all residents. The facility uses a posted menu for meals. The facility has two refrigerators and one separate freezer. The temperatures are kept within regulations requirements. Residents have likes and dislikes and meals are created around that. The facility has 2 days of perishables and 7 days of non-perishables. The facility has an emergency supply of food and water. Incidental Medical and Dental: The facility provide transportation to mecdial and dental appointments for all residents in care. The facility centrally stores medication in a locked cabinet in the medication room. All 6 residents medication was reviewed, no labels were altered, no medications were expired, and medications are being stored in their original containers. Resident Records/Incident reports: The facility has confidential binders for residents records stored in a locked staff office. The facility sends incident reports to the department when required. Five resident files were reviewed for signed Admission Agreements, ID/Emergency information, Consent forms, Medical Assessments, Appraisal Needs and services plans are done on the IPP's, and Safeguard for Property and Valuables. The facility does have the safeguard for cash resources and P&I monies were checked with ledgers, receipts and cash. Disaster Preparedness: The facility has the current disaster forms posted. The forms are legible and complete. The facility conducts quarterly disaster drills changing the type of disasters on each training. The facility has the supplies listed in the disaster plan with food and water. Continued 809-C Residents with special health conditions: The facility does accept dementia residents in care. Sharps, knives, cleaning products are kept locked and made inaccessible to residents in care. The facility does not currently have any residents on hospice, home health services, or using oxygen. If they do have residents on services those plans with be kept up to date. The facility is not using any exiting doors alarms. The facility has video surveillance in the common areas. Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Administrator.