Routine inspection·November 12, 2025

On 11/12/2025 at approximately 09:30AM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to conduct 1-Year Required visit of this licensed Residential Care Facility for The Elderly (RCFE). LPA was greeted by Executive Director, Camille Brown. Facility has an approved fire clearance and capacity for 75 non-ambulatory residents of which 10 can be bedridden. Facility has an approved hospice waiver for 15 individuals and has approval for a secured perimeter. Upon arrival, LPA was informed that there were 45 Residents in care and 22 staff members on-site. At approximately 10:45AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 11:05AM, LPA and Executive Director toured the building and grounds. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is comprised of 5 separate houses for residents which 1 out of 5 house closed temporarily, 1 office building, and facility kitchen. Each house has 13 resident rooms, 3 bathrooms, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for Residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to Residents. Staff were in the process of cleaning bathrooms at the time of this inspection. Water temperature measured 110.6 degrees F and 112.4 degrees F which is within regulation between 105- and 120-degrees F at faucets accessible to residents. LPA also observed activity supply for residents use and residents were in planned activity during the inspection. Continued on LIC809-C Continued from LIC809... Facility's fire extinguishers, smoke and carbon monoxide detectors and sprinkler system were last inspected June 2025. Facility smoke detectors are hard wired and connect directly to the local fire station. Facility's last emergency/disaster drill was conducted October 16, 2025. Fire Extinguishers found to be last charged on 08/07/2025 at the time of visit. Medication is centrally stored and secure. At approximately 2:05PM, LPA reviewed 5 resident records and found 5 of 5 residents have current care plans, signed admission agreements, and physician's report on file. Medication records are thorough and contained physician's orders for each resident. At approximately 2:25PM, LPA reviewed 6 staff records. 6 of 6 records did contain documentation of completed training records as required. Evidence of current first aid and CPR training were current. LPA was presented with proof of certifications. 2 out of 6 staff members did not have Health Screening (LIC503) results and 1 out of 6 staff members TB test result wasn’t in file. (Technical Violation Given). Executive Director agrees to share Health Screening and TB test results with by due date 11/30/2025. Administrator Certificate is for Camille Browm expires 07/24/2026. LPA reviewed the facility emergency disaster plan. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 06/10/2025. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by due date of 11/30/2025: LIC 308 Designation of Facility Responsibility LIC 610 Emergency Disaster Plan (If Changed) Copy/Proof of Updated Certificate of Liability Insurance No deficiencies were observed in the areas inspected, No citations were issued during today’s visit. Exit interview conducted. Copy of report provided to Executive Director. Signature on form confirms receipt of documents.