Routine inspection·August 12, 2025

On August 12, 2025, the Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. The LPA met with the Administrator (ADM), Victoria Regala, and disclosed the purpose of the inspection. The ADM informed the LPA that the facility had five (5) residents in care at the facility, one (1) resident was away at the hospital, and two (2) staff members were present at the time. LPA initiated a walk-through of the facility, accompanied by ADM. LPA inspected the kitchen and observed breakfast preparation and cooking in progress at the time. The appliances were checked and observed to be in working order. The LPA inspected a magnetic locked cabinet containing knives and sharp objects and a magnetic locked cabinet under the sink containing detergents, disinfectants, and cleaning supplies. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No expired food or stored medications were noted. LPA inspected the dining area adjacent to the kitchen. The dining table and chairs were observed to accommodate the residents, and all the furniture was in good repair. Two (2) residents were observed sitting in the dining area eating breakfast. LPA inspected the living room and observed sofa sets, chairs, recliners, a fireplace, work desk, and a television in the living room. LPA observed two (2) hallway closets with bedsheets, blankets, and towels. Continued on LIC809-C There were five (5) bedrooms and two (2) full bathrooms designated for residents' use. Four (4) resident rooms were single occupancy and one (1) was a shared room. LPA inspected three (3) resident rooms and found them clean, well-lit, equipped with the required furniture, and had an exit door to the outside yard. The bathrooms contained soap, grab bars, towels, a trash can, a shower chair, and non-slip mats/flooring. The hot water temperature at the sink faucet measured between 112.5°F to 112.8°F in the bathrooms. LPA observed a utility area with a washer, and a dryer. LPA inspected the attached garage and observed a sofa, refrigerator and freezer containing extra food items. LPA observed multiple storage closets containing silverware, plastic and paper products, beddings, toiletries, and incontinence supplies. LPA inspected the fire extinguisher in the dining area and found it fully charged, with the last service tag dated 03/14/2025. ADM tested the carbon monoxide detector located in the hallway in the LPA's presence, and it was found to be functional. LPA toured the backyard area and found ramps and passageways in good condition, clear of obstructions, with no blocking or tripping hazards. No accessible bodies of water were found. LPA reviewed six (6) staff personnel records and five (5) resident records. The LPA observed that 5 of 5 residents had an Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, Consent forms, Safeguard personal property and valuables, and Personal rights forms. LPA observed that 6 of 6 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 6 of 6 staff members were associated with the facility. LPA observed a locked centrally stored medication cabinet located in the hallway between living room and dining area. Medications were organized separately for each resident. All medication bottles were properly labeled. Centrally Stored Medication Records were reviewed and found to be complete. LPA inspected the first aid kit and found it fully stocked. LPA reviewed Emergency Drill Logs and observed Emergency Disaster Drills were conducted quarterly, with the most recent drill completed on 07/23/2025. Continued on LIC809-C The following updated forms are requested to be submitted to CCLD by 08/19/2025: LIC 500: Personnel Report LIC 308: Designation of Facility Responsibility Certificate of Liability Insurance Administrator Certificate(s) No deficiencies were cited during today's visit. An exit interview was conducted with the Administrator. A copy of this report was provided to the Administrator, Victoria Regala, whose signature on this form confirms receipt of the report.