Routine inspection·March 25, 2026

Licensing Program Analyst (LPA) De Leon arrived at 11:15am to conducted a 1 year annual visit to the facility above. LPA met Administrator Juan Marcos Ibarra 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 submitted an Infection Control Plan to the department. The facility has a sign in and out kiosk for Staff, Residents and visitors. 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. Staff are trained on infection control and the use of Personal Protective Equipment (PPE) upon hire and annual there after. Physical Plant & Environmental Safety: The facility is 10 bedroom with 10 private bathrooms and 1 common areas restroom and 1 staff restroom currently occupying 9 residents and employs 31 staff and 1 Administrator. 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 sprinkler system. The lighting and lamps are sufficient for the use of the facility and for residents comfort. The facility kitchen is clean, safe and sanitary. The showers have non-skid textured floors or mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The facility has a pendant system and pull cords in each residents bathroom. All pathways are clear of any obstruction. 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, Continued 809-C 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 are conducted. Staff handling medications had initial and/or annual training of 8 hours of medication training. Kitchen staff had training on facility policy and procedures for food handling and preparation as well as infection control requirements, some staff had food handler certificates. Trainers met the requirements to train staff with required information present in files. Hospice and Home Health care plans had training records on file. Staffing: The facility employes 31 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed 5 random staff files. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results and Finger print clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate expires 03/29/2027. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. 5 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. Facility does submit incident reports to the department when required. 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 is posted. Internet is provided to each resident with confidentiality and privacy. Planned Activities: The facility offers activities to all residents in care. The facility employs an Activities Director and a monthly calendar with all activities is posted. The facility also offers additional activities to include books, magazines, newspapers, television, daily walks, group discussions and communications, games and puzzles. The facility has sufficient space to allow for activities indoors and outdoors. Food Service: The facility employs food service staff. 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. A menu is posted for residents in care. Modified diets prescribed by a physician are followed for those residents in care. Cleaning solutions and equipment are stored separately than food supply. Continued 809-C Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices. Kitchen Cook has a valid Food Handler Certificate. Incidental Medical & Dental: The facility has a medication cart and it is always kept locked. Facility provides transportation to medical and dental appointments when needed. The facility uses a Medication Administration Record (MAR) and a Centrally Stored Medication Destruction Record (CSMDR) for residents in care. The facility has a mini locked refrigerator for medication and an ice chest for emergency use. The facility has a red sharps container for disposal of syringes. Medication Destruct is done at the Pharmacy or Administrator and staff do it at the facility. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 09/11/2025. 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 in accessible to residents in care. The facility does not have delayed egress. The facility does have residents with oxygen and required signs are posted. The facility currently has 2 hospice residents in care. Hospice care plans are kept on file and up to date when a resident is on hospice services. The facility currently has 2 residents on Home Health services. Home Health services records are kept on file if a resident is on services. The facility is a secured perimeter with a locked key coded gate for entry and exit. The facility has key coded locked gates on the enclosed patio in the back of the facility. LPA conducted interviews with 2 Staff and 2 residents. Exit interview conducted, no deficiencies cited, copy of report printed for Administrator.