Routine inspection·November 5, 2025

On 11/05/2025, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced required - 1 year inspection visit. LPA met with administrator/licensee Ante Buljan and explained the purpose of today's visit. There are currently 7 residents in care and 4 staff present. This is a multi level facility. The second floor is where the licensee resides. licensed for residents age range of 60 years and over all of which may be non-ambulatory. License is approved for 5 hospice residents. Room 4 is the only cleared bedridden room. There are 2 hospice residents as of today's inspection visit. The physical plant was toured inside and outside of the facility to ensure the safety of the residents. There are no video cameras on site per the caregivers. LPA observed the facility kitchen which is clean and observed appliances that are in good repair. Knives are stored and locked in a drawer next to the sink. Perishable and non-perishable food items are observed as being in place meeting both the 2 day fresh food supply and 7 day emergency food supply requirement. There is an additional refrigerator/freezer in the garage area which carries additional food supplies for resident use. PPE and incontinence supplies are also stored in the garage area as in place. First aid kits are observed as complete with required items stored in the kitchen of the facility. Medications are observed to be locked in the kitchen in a kitchen cabinet. LPA observed at least two fire extinguishers in place which are currently within operating range, hard wired smoke detector, carbon monoxide detectors are observed in place through out the facility, and central heating/air conditioning. LPA also observed two fire pull stations in the rear and front of the facility. Continued on next... Page 2 Emergency exit routes are observed inside and outside to be free and clear of obstructions. Emergency disaster drill last conducted on 10/06/2025. Water temperature was measured at 120F in the kitchen and in a resident room in the back of the facility. Cleaning supplies are observed to be locked in the kitchen below the sink, garage, and laundry room. LPA observed the laundry room, and both laundry and dryer are operational. LPA observed all resident rooms as clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident bathrooms are observed as clean and in good worker order. All resident room have their own full bathroom with showers. Shower floors are equipped with non-skid mats or flooring. Facility has two fire extinguisher present. Both are charged and ready for use with inspection dates on 10/02/2025. Medications and logs are observed today as current. During today's inspection LPA reviewed 7 resident file and 4 staff files, which are all current. Administrator certificate for Ante Buljan is observed as expired on 01/10/2027. The following updated forms are requested to be submitted to CCLD by 11/12/2025 : • Copy of updated Administrator Certificates There are no citations issued on this day. Report is reviewed with the licensee Ante Buljan and a copy is provided.