Routine inspection·March 26, 2026

Licensing Program Analyst (LPA) De Leon arrived at 10:45am to conducted a 1 year annual visit to the facility above. LPA met with Back up to 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, hand soap, and hand washing signs. 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 & Environment Safety: The facility has 10 bedroom/10 bathroom for residents, 3 common area restrooms with coded locked doors, kitchen, dining room, laundry room, activity room, code locked office with locked medication closet, currently occupying 10 residents with 14 staff of which 2 are administrators. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has dual smoke and carbon monoxide detectors with a sprinkler system. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The facility kitchen is clean, safe and sanitary. 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 basement, cleaning closet and laundry room. The facility has sufficient space inside and outside for activities and visiting. The facility has an enclosed courtyard for client use with plenty of shade gates are locked by a key fob which automatically open with fire alarms. The facility has telephone and internet service for resident use. Continued 809-C The facility has video surveillance in the common areas without voice or sound capability for privacy purposes. The flooring is going to be replaced due to peeling and lifting, LPA found no tripping hazards in the flooring on the tour, the staff peel away anything lifting and put gorilla tape over the flooring so it does not cause a hazard. Administrator will send incident report with details of when the repairs will start and end and the plan for residents when each room is being done. 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 did not have proof of insurance at visit and will send copy to LPA. The facility is approved for a capacity of 13, with 13 Non-Ambulatory of which 12 may be bedridden. Hospice waiver is approved for 8. The facility is currently working on securing a fire clearance for delayed egress and secured coded locked gates for entry and exit, a this time it is not being utilized until the fire chef and company that is doing the install can met and go over it together then it will be granted by Fire for use. Staffing: The facility employes 13 staff of which 2 are certified Administrators. Staff records are kept confidential. Five 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. Administrator Certificates expire 03/11/2028 and 08/27/2027. Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 5 staff training records for Initial and/or Annual Training Requirements of 20 plus hours meeting 8 hours of dementia training with all subjects covered over a 3 year period, 4 hours of hospice care, postural supports and restricted health condition, and 8 hours of other training to include ADL's, resident characteristics, emergency preparedness policy and procedures, infection control requirements and Quarterly Disaster Drills. Staff handling medications had annual training of 8 hours of medication training. Hospice and Home Health provide training to staff for residents under those services and facility keeps records on file. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Five files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Pre-Admission appraisals are conducted on perspective residents before accepting them into care. The Facility does not handle cash resources on residents in care. Facility does submit incident reports to the department when required. Continued 809-C 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. 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 in office. Medication were checked for expiration, llabels were not altered 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/Family 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 along with CCL reports and PIN's were posted. Visitation policy is posted at entry. Internet and a device for residents use is provided to residents with confidentiality and privacy. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers was charged and last inspected July 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 5 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 services records are kept on file. The facility does not currently have delayed egress, forms have been submitted to the department and fire for clearance. The facility has exiting door alarms. LPA conducted interviews with 2 residents and 2 staff. Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Administrator.