Routine inspection·April 17, 2026

Licensing Program Analyst (LPA) De Leon arrived at 12:00pm to conducted a 1 year annual visit to the facility above. LPA met with Back up to Administrator Edwin Ingan and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has an Infection Control Plan on file. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. The staff take infection control training annually. Physical Plant & Environment Safety: The facility is a 3 bedroom and 2 bathroom home currently occupying 4 residents and 2 full-time staff with 6 relief staff and additional Administrators. The facility is clean, safe and sanitary. The pathways are clear of any obstructions. The facility has sufficient space inside and outside for activities and visiting. The gates are self closing and self latching. The facility has table and chairs available outside with shaded area for resident use. Laundry room has working washer and dryer. Operational Requirements: The Facility is operating in compliance with fire clearance. The facility provided current up to date liability insurance. All Dementia requirements are being met. Hospice wavier granted for 3. The facility has 1 residents on home health services. The facility currently has 2 hospice residents. Facility currently had 1 resident on oxygen, signs are posted on the front door and bedroom wall. Personnel Records & Training: The facility keeps confidential files on each staff member. Training records were up to date for 2025-2026 annual training requirements. Continued on 809-C Staffing: The facility employes 6 staff and staff records are kept confidential. Staff records were reviewed for 4 current staff. Staff records had finger print clearance and associations with criminal record statements, personnel record or application, First Aid and CPR certificates and Health screening with TB results. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Facility does submit incident reports to the department when required. Resident Rights Information: All require posting for residents were posted in common areas of facility. Personal rights, Rights to Resident Council, Theft and Loss policy, CCL Complaint poster, and LTCO poster. Nondiscrimination notice, and Signed Admission Agreements. Planned Activities: The facility offers activities to all residents in care. Activities include books, magazines, newspapers, TV watching, daily walks, group discussions and communications, arts and crafts. The facility has sufficient space to allow for activities indoors and outdoors. Interviews with residents revealed they do what they want to do for their leisure. Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. Food, snacks and drinks are available when the residents want them. Incidental Medical & Dental: Facility provides transportation to medical and dental appointments when needed. The medications records were reviewed facility uses both Medication Administration Records (MAR) and Centrally Stored Medication and Destruct Records (CSMDR). All medications were in original containers, Prescription labels were not altered, and none of the medication were expired. The doctors orders were present and dispensing instructions were followed. Disaster Preparedness: The current emergency disaster forms were posted and up to date. The facility provided copies of quarterly disaster drills. The fire extinguishers were charged and last inspected on 10/24/2025. The dual smoke and carbon detectors are present and hard wired throughout the facility with sprinkler system. Residents with Special Health Needs: The facility has dementia residents in care. All items that could pose a danger, sharps, cleaners were locked separately in cupboards. The facility has a license for 1 bedridden in room #2 only. The facility does not have any delayed egress. LPA conducted interviews with 2 Resident and 2 Staff. Exit interview conducted and copy of report printed for Administrator.