Routine inspection·May 12, 2026

Licensing Program Analyst (LPA) Rankin arrived at 10:56 am and made an unannounced 1-year required annual visit to the facility above. LPA met with Ana Martinez, Administrator 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 extinguishers were last charged and inspected on 07/14/2025. The facility is a four (4) bedroom and three (3) bathroom facility currently occupying four (4) residents. There are two (2) additional restrooms inaccessible to residents and for staff only. The facility has hard wired, dual smoke and carbon monoxide detectors that were tested. 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 secure grab bars are present. The showers have non-skid flooring. The pathways are clear of any obstructions. Disinfectant, cleaning solutions are inaccessible to residents in care locked and stored in the laundry room and or locked under kitchen sink. 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. Operational Requirements: The facility has current liability insurance. 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 is approved for a capacity of four (4). Fire clearance is granted for four (4) Ambulatory of which three (3) may be non-Ambulatory and one (1) may be bedridden. Staffing, Personnel Records & Training: The facility currently employs six (6) full-time staff, 2 part-time staff, one (1) registered nurse, one (1) Facility Manager and one (1) administrator. Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, and Health screening with TB results. Administrator Certificate expires 06/11/2027. Staff have annual training for various subjects/topics for 2025 and 2026. Continued on 809-C Additional topics on Dementia care were requested in a Technical Violation during 2025 annual visit, facility did not meet the required annual hours for dementia during this annual visit, citation given. Medication training on two (2) staff who assist in medication was reviewed. Training for medication has not been done since 2024, annual training is required. Facility has scheduled Medication training for May 19 th and 20 th , due to the delay in the training a citation is issued. Resident Records & Incident Reports: Facility does submit incident reports to the department when required. LPA reviewed four (4) resident files, for but not limited to signed Admission Agreements, Personal Rights, Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, (TCRC IPP), Emergency and ID forms, all forms were legible. Facility utilizes different forms for the Physician Assessment, which is missing details typically reviewed by the LPA. Technical given to request additional items be reviewed prior to admitting a resident and annual thereafter. 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 requirements. All food is covered, stored, and marked appropriately. Kitchen is clean, no evidence of insects or rodents. 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). Facility does not utilize the state’s Centrally Stored Medication and Destruct Records (CSMDR), but does keep records noted in regulation. Updates to their processes were requested to ensure all items were documented for CSMDR requirements. LPA reviewed 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 monthly disaster 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 does accept dementia residents in care. The facility has 2 self-latching gates on each side of the home. The facility does not have delayed egress, locked doors or gates. Exit interview conducted and copy of appeal rights and report printed for Administrator.