Pre-licensing visit·July 8, 2025

On 07/08/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year inspection. LPA met with administrator Michelle Roias and explained the purpose of today's visit. Currently there are 6 residents in place and 2 staff present on this day. One of which is the administrator. The facility is licensed for age range 60 and over. All may be non-ambulatory. The facility has a hospice waiver requested for 2. There is currently 1 residents on hospice. This is a single level facility. The facility ambient temperature is comfortable. LPA observed the facility's emergency food supplies such as canned goods and they are in place. There are 6 resident rooms. All rooms contain a half bathroom. Water temperature is tested in the common hallway full bathroom measuring as 110F. Cleaning supplies are observed to be locked in the garage. Facility knives are observed to be in a drawer adjacent to the refrigerator. Kitchen food supplies are observed to be in place with 2 day fresh food supply and canned goods fulfilling the 7 day emergency food supply. The garage has two additional refrigerators with A tour of the outside of the facility is conducted. Emergency routes are free and clear of any obstructions. At the rear of the facility lot is a separate dwelling that is rented out privately. There is no connecting entrances from the facility to that dwelling. Smoke detectors and carbon monoxide detectors are located through out the facility as well as fire sprinklers. The facility is also equipped with 1 fire alarm pull in the front of the facility. LPA observed 2 fire extinguishers in the facility with inspection tags dated 04/07/2025. Facility conducts emergency drill quarterly. The last drill that was conducted is logged and posted in the main hallway with a date of 04/18/2025. Linens are in place for resident use in each resident room. Continued on next page... Page 2 LPA observed all resident rooms and observed that they contain the required furniture and lighting as outlined in Title 22. Medications, medical kit, and sharps are stored in locked medication closet near the front of the facility. Toilet and bathing facilities are equipped with grab bars. Hygiene supplies are in place. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed as current. LPA reviewed 4 staff files and 4 resident files on this day which appear to be current based on review. Staff training records are observed to be current and in place. Administrator certificate for Michelle Roias is observed as current expiring 12/10/2026 Component III is conducted on this day with Michelle Roias. No citations issued on this day. LPA will notify CAB of completion of this prelicensing inspection to recommend its licensure. Report is reviewed with Michelle Roias and a copy is provided.