Routine inspection·March 27, 2026

Licensing Program Analyst (LPA) Rachael De Leon arrived at 10:30am to conducted a 1 year annual visit to the facility above. LPA met Administrator Stephanie Avila 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) on hire and annual there after. Physical Plant & Environment Safety: The facility is 14 bedroom with 14 private bathrooms and 1 common areas restrooms currently occupying 13 residents and employs 15 staff of which 3 certified 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, hard wired 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, 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. Continued 809-C 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 15 staff and 3 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 01/08/2028. 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 along with CCL report. 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. 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. Continued 809-C Incidental Medical & Dental: The facility has a medication carts that are kept locked in locked medications closets. 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 by administrator and staff do it at the facility. Medications were checked for expiration, no labels altered and all medications stored in original containers. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 05/20/2025. 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 does have 5 residents on hospice services. Hospice care plans are kept on file and up to date when a resident is on hospice services. The facility does currently have 3 residents on Home Health services. Home Health services records are kept on file if a resident is on services. The facility entry door is locked to enter only, anyone can exit at all times. Entry and exit doors and gate are alarmed. The courtyard has a gate that is locked to enter but is unlocked to leave trough at any time. LPA conducted interviews with 2 Staff and 3 Residents. Exit interview conducted, no deficiencies cited, copy of report printed for Administrator.