Routine inspection·November 19, 2025

Licensing Program Analyst (LPA) Rankin arrived at 9:15 a.m. to conduct a 1-year required annual visit. LPA met with Andrea Rivera, Administrator. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Physical Plant & Environment Safety: LPA toured resident rooms and observed that rooms were tidy, the lighting and lamps are sufficient for the use of the facility and for resident comfort and safety. Toilet, hand washing and bathing facilities are operational. The showers have non-skid mats. The pathways are clear of any obstructions. The facility has sufficient space inside and outside for activities and visiting. The facility has telephone and internet service for residents’ use. The fire extinguisher was last charged and inspected on 8/11/25. The carbon monoxide and smoke detector was tested and working. 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 is approved for a capacity of 6. The fire clearance is granted for 6 non-ambulatory residents. There is a hospice waiver for 1 resident. Staffing and Training: The facility currently employs 5 staff and 1 administrator. Files reviewed had current 1st Aid/CPR. Files had all required documents per regulation standards. Administrator Certification expires 05/31/2027. Training for 2025 was reviewed and completed. Continued on 809-C Resident Records & Incident Reports: The facility keeps separate confidential files on each resident. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, Physician reports, Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms. All forms were legible and complete. Food Service: The facility has 2-day perishables and 7-day non-perishables to meet the food service requirements. All food is covered, stored, and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies. Incidental Medical Services: Facility provides transportation or assists in providing transportation to medical and dental appointments when needed. The facility uses the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed a sampling of residents’ medications, no medications were expired, and all medications were kept in their original containers. Disaster Preparedness: The current emergency disaster forms were reviewed. The facility conducted a quarterly disaster drill on 10/18/25. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Exit interview conducted and copy of report printed.