Routine inspection (multi-day)·November 12, 2025

Licensing Program Analyst (LPA) De Leon arrived at 1:50pm to conducted a 1 year annual visit to the facility above. LPA met with Back up Administrator Leticia Ruiz 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 a current Infection Control Plan. The facility has a sign in and out clipboard for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, and hand soap. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. 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). Physical Plant & Environmental Safety: The facility is a 4 bedroom with 3 bathrooms, kitchen, dining room, locked laundry room, locked storage room off the master bathroom, locked medication closet currently occupying 5 residents and employs 8 staff. The facility is clean, safe and sanitary. 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. The facility kitchen is clean, safe and sanitary. The knobs are taken off stove to make it inaccessible to dementia residents in care, the hall has a sliding gate that closes off to the kitchen at night and it does not lock. 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 for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked in the laundry room. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard with in enclosed patio and an open patio for resident use with plenty of shade. The facility has telephone and internet service for resident use. The facility has video surveillance in the common areas without voice or sound capability for privacy purposes. Cont. 809-C Operational Requirements: The facility has a current plan of operation on file. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance. The facility is approved for a capacity of 6 with 6 Non-Ambulatory of which 1 may be bedridden. Hospice approved for 6. Staffing: The facility employes 7 staff and 1 Administrator. Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate. Administrator Certificate expires 08/27/2027. The facility keeps confidential files for each staff member. Personnel Records & Training : LPA reviewed 5 staff training records for Initial 40 hours and/or Annual Training Requirements of 20 plus hours for 2025. All files reviewed had ADL's, resident characteristics, emergency preparedness policy and procedures, infection control requirements and Quarterly Disaster Drills. Resident Records & Incident Reports: Completed on last visit to facility. 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. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices. The kitchen has a gate that opens and closes to keep range and ovens inaccessible to dementia residents in care. Incidental Medical and Dental Services: Facility provides 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). Medications are kept in a locked medication closet. Medication were checked for expiration dates, no altered labels, and medication were stored in original containers. Administrator and Medication Technicians destroy medications by logging and taking to the pharmacy for destruction. Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster and LTCO poster were posted in the common areas of facility. The current license was posted. Visitation policy is posted at entry. Internet and a device for residents use is provided to resident with confidentiality and privacy. Continued 809-C Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers was charged and last inspected 08/28/2025. 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 does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not currently have residents with oxygen. The facility has 3 hospice residents in care. Hospice care plans are kept on file and up to date. The facility currently has 1 resident receiving Home Health services. Home Health records are kept on file. The facility does not have delayed egress. The facility has exiting door alarms. LPA conducted interviews with 2 residents and 2 staff. Exit interview conducted and copy of report printed for Administrator.