Routine inspection·November 7, 2025

Licensing Program Analyst (LPA) Rankin arrived at 12:25 p.m. to conduct a 1-year required annual visit. LPA met with Amelita Aquino, Administrator and Thelma Tablada. 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/flooring. 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 10/18/24. Administrator will send receipt for purchase of new fire extinguisher. The facility has carbon monoxide and smoke detectors that were 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 4 non-ambulatory and 2 ambulatory residents. Facility has a hospice waiver for 6. The facility currently has 1 ambulatory and 3 non-ambulatory. (Continued on 809-C) Staffing and Training Records: The facility currently employs 5 staff and 2 administrators. Files reviewed had 1st Aid/CPR, Personnel Records/Application, TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. Resident Records & Incident Reports: The facility keeps separate files on each resident confidential. Facility does submit incident reports to the department when required. LPA reviewed 4 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, Physicians reports, Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms. All forms were legible. 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 and are inaccessible to residents in care. 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) and Medication Administration Records (MAR). LPA reviewed a sampling of residents’ medications, no medications were expired, and all medications were documented and tracked. Disaster Preparedness: The current emergency disaster forms were posted. The facility last conducted a quarterly disaster drill/training on 11/3/25. 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.