Routine inspection·May 28, 2025

On 05/28/2025, Licensing program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection. LPA met with Administrator Jennifer Tobias and explained the purpose of today’s visit. Currently there are 6 residents and 3 staff present. One of which is the administrator. This is a single level facility with 6 bedrooms for residents. The facility is licensed for age 60 and over. All may be non-ambulatory. With a hospice waiver for 3 residents. At this time there is 1 resident under hospice care. LPA Vado toured the facility both inside and outside. All outdoor and indoor passageway are free and clear of obstructions for emergency exit routes in case of fire or emergency. Facility's ambient temperature is comfortable for residents and LPA. No pools or bodies of water were observed during today's visit on the premises. LPA observed fresh food supplies and emergency one week of nonperishable and two (2) days of perishable foods as in place. Dry goods/can goods are stored in a cabinet located in the garage. Knives are locked with cleaning supplies below kitchen sink. Toxic chemicals/cleaning supplies are also observed to be locked in the garage of the facility in a cabinet adjacent to the laundry area. Both the washer and dryer are observed as functional. There is are an additional 2 refrigerators located in the garage for resident and staff items. Medications are observed as locked in cabinets next to the kitchen stove. Each resident room observed contained the required furniture as outlined in regulations. All resident room also have a half bathroom with exception of bedroom 5, which has a full bathroom with walk in shower. There is an additional full bathroom located near the front of the facility next to the dining room in a small hallway where the staff room is located. Facility has functioning smoke detectors within the facility as well as carbon monoxide detectors located through out. Fire extinguishers are observed with inspection dates of 01/28/2025. Water temperature is tested at 105F in full bathroom attached to room 5. Continued on next page... Page 2 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. LPA observed resident linen supplies stored in a hallway closet adjacent to staff room. Shower floors are equipped with non-skid mats or flooring. LPA inspected the medications and files of 5 residents in care at the facility. Based on review of all resident files, and medications all items are current and logged accurately. 4 staff files are reviewed and they are observed as current. Disaster/fire drill log is reviewed. Disaster drill observed as conducted on 01/31/2025 per record reviewed. Facility administrator certificate for Jennifer Tobias is observed as current expiring 11/08/2025 based on online review of her certificate. The following updated forms are requested to be submitted to CCLD by 06/04/2024 : • Copy of updated administrator certificate • 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 There are no citations issued on this day. Report is reviewed with administrator Jennifer Tobias and a copy is provided.