Routine inspection·November 20, 2025

Licensing Program Analyst (LPA) De Leon arrived at 10:10 am to conduct a 1 year annual visit to the facility above. LPA met with Administrator, Jessica Guerrero 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 & Environmental Safety: The fire extinguisher were charged and tagged 06/04/2025. The facility has 3 wings: North, South and a West. This facility has 30 resident rooms, 22 bathrooms with Front desk, Sitting area, Lounge, Kitchen, Dining room, laundry room and fenced courtyard with fountain filled with river rock. The facility is completely fenced with a open gate for entry and another large gate for exiting, gates are kept open during business hours. The facility has dual smoke and carbon monoxide detectors which are hard wired and 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 secured grab bars and 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 and stored in locked storage rooms and laundry room. The facility has sufficient space inside and outside for activities and visiting. The facility has a patio with furniture, pergola 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 12/2026. The facility is approved for a capacity of 60. The fire clearance is approved for 60 Non-Ambulatory, which 10 may be bedridden in any room. Hospice wavier approved for 10. Staffing: The facility currently employes 23 staff, and 3 Administrators. Staff records are kept confidential. Five Staff files were reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, and fingerprint clearance or exemptions. Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed training files for 5 Staff. Annual training completed for 20 plus hours from 2024-2025 or 40 plus hours of initial training hired in 2025. All required subjects and topic are covered. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for signed Admission Agreements, Safeguard for property and valuables, LIC. 602A Physicians report, Appraisals Needs and Services Plan, Consent forms and Emergency/ID forms. 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 in a storage room. Kitchen has hot tap faucets with safety signs posted. An adequate amount of emergency food and water is present. Incidental Medical/Dental Services: Facility provides assistance in arranging transportation to medical and dental appointments when needed. Residents have on-call doctor and nurse practitioner that visits facility. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed residents’ medications in the north medication cart, no labels were altered, no medications were expired and all medications were kept in their original containers. The facility has 3 wings and 3 medication carts kept locked. Continued 809-C Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. Emergency exits and telephone numbers were posted. Codes are available for staff on all shifts to access full facility in an emergency. The facility had an annual Fire inspection in April 2025. 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 residents on Oxygen and signs are posted. The facility has 6 residents on hospice services. The facility currently has 4 residents on home health services. Hospice and Home Health Plans are kept up to date and on file at the facility. Exit interview conducted and copy of report printed for Administrator.