Routine inspection·April 10, 2026

Licensing Program Analyst (LPA) De Leon arrived at 1:31 pm to conduct a 1 year annual visit to the facility above. LPA met with 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, hand soap, and hand washing signs. The facility has EPA approved disinfectant 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 & Environment Safety: The fire extinguisher were charged and tagged. The facility has 19 resident bedrooms with on suite bathrooms, 2 guest bathrooms and 1 staff bathroom. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors dual and hard wired with a sprinkler system. 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 or textured bottoms. 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 and stored in locked storage rooms. The facility has sufficient space inside and outside for activities and visiting. The facility has a patio with furniture and umbrella for shade and resident use. The facility has telephone and internet service for resident use. Continued 809-C 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 on April 29, 2026. The facility is approved for a capacity of 25. The fire clearance is granted for 25 non-Ambulatory, 25 of which may be bedridden. Hospice is approved for 8. Staffing: LPA will return to complete this portion of the annual visit. Personnel Records & Training: LPA will return to complete this portion of the annual visit. Residents Rights & Information: LPA will return to complete this portion of the annual visit. Resident Records & Incident Reports: LPA will return to complete this portion of the annual visit. Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables and plenty extra, 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. Kitchen has a hot and cold water machine the hot is designated with red and a hot sticker in red to notify of hot water. The kitchen door is key coded for entry into the commercial kitchen. Incidental Medical Services: Facility provides assistance in arranging transportation to medical and dental appointments when needed. Residents have on-call doctor that visits facility. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed all residents’ medications, no labels were altered, no medications were expired and all medications were kept in their original containers. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. Emergency exits and telephone numbers were posted. Keys and Codes are 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 sharps, knives, cleaning products and items that can pose a hazard are locked in storage rooms. The facility currently has 2 resident on Oxygen and signs are posted. The facility has 1 resident on hospice services, The facility currently has 8 residents on home health services. Hospice and Home Health Plans are kept up to date and on file at the facility. Exit interview conducted, no deficiency cited and copy of report printed for Administrator.