Routine inspection·August 6, 2025

Licensing Program Analyst (LPA) Rankin arrived at 9:46 am and made an unannounced 1-year required annual visit to the facility above. LPA met with Claire Aviado, administrator designee 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 has 5 bedrooms and 3 bathrooms currently occupying 5 residents. The facility has smoke and carbon monoxide detectors that were tested and working at time of visit. The lighting is sufficient for the use of the facility and resident comfort. The toilet, hand washing and bathing facilities are operational and secure grab bars are present. The showers have non-skid mats/flooring. The pathways are clear of any obstructions. Disinfectant and cleaning solutions are inaccessible to residents in care and are locked in a cupboard in the garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use with plenty of shade. Operational Requirements: The facility has current liability insurance that expires on 9/11/25. 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 2 bedridden residents. A hospice waiver is approved for 2 residents. Continued 809-C Personnel Records & Training: The facility currently employs 5 full-time caregivers, and 3 administrators. Records are kept confidential. Files were reviewed for, but not limited to current 1st Aid/CPR, Health screening with TB results, Criminal Record statements, files were complete. The administrator file was reviewed for Continuing Education requirements and Administrator Certificate expires 8/14/25. Staff have annual training completed for various required subjects/topics and hours for 2025. Resident Records & Incident Reports: The facility keeps resident records confidential. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for, but not limited do, current Physician Records and Appraisals Needs and Services Plan, Emergency and ID forms, all forms were legible, and records are kept complete. Food Service: The kitchen and storage areas were clean and maintained. The facility has 2-day perishables and 7 day non-perishables to meet the food service requirement. All food is covered, stored, and marked appropriately. The current menu and ingredients were present. Incidental Medical Services: Facility provides or assists in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed residents’ medications, no labels were altered, no medications were expired, and all medications were kept in their original containers. Additional medication processes are being implemented. Disaster Preparedness: The current emergency disaster forms were posted. The facility last conducted a quarterly disaster drill 3/2025. 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. The fire extinguishers were last charged and inspected on 4/23/25. Residents with Special Health Needs: The facility does accept dementia residents in care. The facility does not have delayed egress, locked doors or gates. Exit gate alarms are working. Exit interview conducted and copy of report printed for Administrator.