Routine inspection·March 17, 2026

Licensing Program Analyst (LPA) Rankin arrived at 8:29 am to conduct a 1-year annual visit to the facility above. LPA met Administrator Allan Sepulveda and explained the purpose of the visit. 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: The facility is a 6 bedroom and 4 ½ bathroom, with 1 bedroom and ½ bathroom dedicated to staff. The facility occupies 6 residents and employs 3 full-time staff of which one is the Administrator, and one is a live-in staff. Facility has 3 on-call staff if needed. The facility is clean, safe and sanitary. The facility has smoke and carbon monoxide detectors which were tested and working properly during the visit. The lighting and lamps are sufficient for the use of the facility and for resident comfort and safety. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Disinfectants, cleaning solutions and poisons are stored under kitchen sink and in the garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard for client use with furniture and plenty of shade. The backyard has 3 locked sheds to store extra furniture and items. Operational Requirements: The facility has a current plan of operation on file. The Facility is operating in compliance with the granted fire clearance based on the facility sketch. The facility has current liability insurance and expires on 03/20/2026, the updated form will be emailed to LPA at the end of the week when the renewal document is received. The facility is approved for a capacity of 6 non-Ambulatory and approved for hospice waiver of 6. Continued 809-C Staffing, Personnel Records & Training: Staff records are kept confidential. LPA reviewed staff files. Staff files were reviewed and contained current First Aid/CPR certification, and all other documents required by regulation. Administrator’s Certificate expires on 7/13/26. LPA reviewed staff training records for Annual Training Requirements of 20 plus hours. Initial training was kept on file. Resident Records & Incident Reports: Resident files were reviewed and contained the required documentation, including but not limited to updated LIC 602A Physician’s Reports, identification and emergency contact forms, Appraisal/Needs and Services Plans (ANS), and TB test results. All files reviewed were found to be current. Incidental Medical & Dental : The facility has a medication cabinet in the family room that is kept locked. Facility provides or assist in providing transportation to medical and dental appointments when needed. The medications records were reviewed and all residents in care had a Centrally Stored Medication Destruction Record (CSMDR). LPA reviewed a sampling of residents’ medications, no medications labels were altered, and medications were stored in original containers. Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7 day non-perishables to meet the food service requirement. All food is covered, and stored appropriately. Food, snacks and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Disaster Preparedness : The current emergency disaster forms were posted. The facility conducts quarterly disaster drills last one on 3/14/26. The fire extinguisher is charged and was inspected on 4/14/25. The next inspection is due in April. A set of keys is available for staff on all shifts to access full facility in an emergency. Residents with Special Health Needs: The facility does accept dementia residents in care. The facility does not have delayed egress. The facility does have 1 resident with PRN oxygen available if needed. The facility does have 4 hospice residents in care. The facility has 2 resident currently on Home Health services. Exit interview conducted and copy of report printed for Administrator.