Routine inspection·March 12, 2026

Licensing Program Analyst (LPA) Rankin arrived at 9:22 am to conduct a 1 year annual visit to the facility above. LPA met with Administrator Amelita Antonio and Juanito Pasion 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: Physical Plant & Environment Safety: The fire extinguisher was last charged and inspected on 2/25/26. The facility has 4 resident bedrooms and 2 bathrooms currently occupying 2 residents. The facility has smoke and carbon monoxide detectors which were tested and working at time of visit. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid flooring. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant and cleaning solutions are inaccessible to residents in care and locked in laundry room cupboards. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use with plenty of shade. The facility has telephone and internet service for resident use. Operational Requirements: The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 12/30/26. The facility is approved for a capacity of 6. The fire clearance is granted for 6 Non-Ambulatory of which 2 may be bedridden. Hospice is approved for 4. Staffing, Records & Training: The facility currently employs 1 full-time and 2 Administrators and has additional on call staff if needed. Staff records are kept confidential. Files reviewed had current 1st Aid, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. Current Administrator Certificates will expire 08/02/27 and 03/22/28. Staff have annual training completed for all subjects/topics and hours for 2025. Continued 809-C Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 2 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, LIC. 602A Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms, all forms were legible, and records are kept confidential. 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. All food is covered, stored and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies. Incidental Medical Services: Facility provides transportation or assists in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed a 2 residents’ medications, no labels were altered, and all medications were kept in their original containers. Caregiver was able to clearly explain the process, all records are clear, and update to date. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills and monthly fire drills. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Residents with Special Health Needs: The facility accepts dementia residents in care. The facility has 1 gate on the side of the home. The facility currently has 1 resident with dementia. All door and gate alarms were operational. Exit interview conducted and copy of report printed for Administrator.