Routine inspection·November 13, 2025

Licensing Program Analyst (LPA) De Leon arrived at 1:30 pm to conduct a 1 year annual visit to the facility above. LPA met with back up Administrator Rachelle Tellez and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, and hand soap. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires in April 2026. The facility is approved for a capacity of 22. The fire clearance is granted for 22 Non-Ambulatory of which 18 may be bedridden and Hospice is approved for 8. Physical Plant & Environment Safety: The fire extinguishers were last charged and inspected on July 14, 2025. The facility is a 17 bedroom, 13 resident bathrooms and 3 common areas restrooms, 2 living rooms, 2 kitchens, 2 dining rooms, activity room, 2 laundry rooms, staff area with lockers, and beauty parlor. The facility is currently occupying 15 residents in care and employs 20 staff and 2 Administrators. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care and locked in cupboards and closets. Continued 809-C The facility has sufficient space inside and outside for activities and visiting. The facility has plenty of shade. The facility has telephone and internet service for resident use. The stairway carpeting to both stairwells is in need of carpet cleaning, Administrator has appointments to have it completed. The facility has emergency chairs for stairwells. Fireplaces have screened covers for safety. Resident Rights/Information: The facility had postings for Personal Rights and non- discrimination, Emergency Disaster plan, Facility sketch, Visiting policy with hours, Rights to Resident Council and family council, CCL PINS, and CCL reports. All postings were posted at front entry or in the common areas of the facility. CCL and LTCO complaint posters are posted. Planned Activities: The facility has a large room for activities and plenty of supplies for activities in two large cupboards, any items that can pose a danger were inaccessible to residents in care. The facility has an activity calendar posted in several areas. 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. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies. The facility has additional food and water for an emergencies. Incidental Medical and Dental: The facility provides or assist in providing transportation to medical and dental appointments. The facility has a locked medication room for all centrally stored medications, PRN medications, and first aid supplies. Medication room has a red sharps container for disposal. Administrator and another staff work together to destroy medication at facility when required. The facility uses an electronic Medication Administrator Record (MAR) and uses the Centrally Stored Medication and Destruction Record (CSMDR). All medications were audited for expiration dates, altered labels and medications stored in original containers, no deficiencies found. Residents with Special Health Needs: The facility does accept dementia residents in care. Facility does not currently have any residents using oxygen. The facility currently has hospice residents in care, plans are kept on file. The facility currently has residents receiving Home Health services and plans are kept on file. The facility does not have delayed egress. The facility has a large driveway with gate at entry and a calling system to access gate for car entry. The facility has a court yard at entry with a self closing gate. The property has other buildings on the premises but are not part of the license. LPA will return at a later date to review records and conducted interviews. Exit interview conducted and copy of report printed for Administrator.