Routine inspection·July 10, 2025

On 07/10/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced prelicensing inspection. LPA met with administrator Maria Roias and explained the purpose of today's visit. There is 2 staff and 3 residents present. LPA was allowed entry into the facility. This is a single level facility that is cleared to be all non-ambulatory residents and one bedridden resident in room #4 . Hospice waiver for 2. There are no hospice residents or bedridden residents at this time. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed the facility kitchen and observed appliances are in good repair. Knives are stored and locked in the medication closet located in a small hallway near room 1. Medications are observed to be locked in a medication closet which appeared organized and well kept. Perishable and non-perishable food items are observed as in place. There is an additional freezer in the garage area that houses facility food. First aid kit is observed as complete with required items. LPA observed that there are two fire extinguishers in place with an inspection date of 05/27/2025, smoke detector/carbon monoxide detectors are observed in place through out the facility, and central heating/cooling system in place. Facility is equipped with fire sprinklers through out the physical plant. PPE and additional incontinence supplies are in place. Laundry area is also observed as fully operational located in the garage. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 06/26/2025. Continued on next page... Page 2 Water temperature was measured at 107F in resident room. All resident rooms contain a half bathroom for resident use. There is a common shower room for residents that use non-skid mats in place. LPA observed rooms at random and all appeared clean, and contained all the required furniture per regulatory recommendations. Resident linen supplies are observed as in place in a hallway closet adjacent to the dining room. LPA reviewed 5 resident files and also reviewed 3 staff files on this day. Per resident files reviewed, they are current. Per staff files reviewed, all files were current with training and CPR/First Aid. Client medications are inspected and are current including facility medication administration records. Administrator certificate is observed as current via the CDSS website as the administrator, Terry Illastron, is expiring on 12/4/2025. The following updated forms are requested to be submitted to CCLD by 07/17/2024 : • Copy of facility's liability insurance • LIC308 Designation of responsible staff person • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule • Copy of control of property or copy of lease No citations issued on this day. Report is reviewed with Terry Illastron.