Routine inspection·November 13, 2025

On 11/13/2025 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 Administrator, Jethro Nicolas. Facility has an approved fire clearance and capacity for 4 non-ambulatory residents. Facility has an approved hospice waiver for 2 individuals. Upon arrival, LPA was informed that there were 4 Residents in care and 3 staff members on-site. At approximately 10:30AM, 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 Administrator toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Staff were in the process of cleaning up kitchen at the time of this inspection. Toxins are stored in a locked housekeeping closet in the laundry room and in the garage. Water temperature measured 106.6 degrees F and 108.4 degrees F which is within regulation between 105- and 120-degrees F at faucets accessible to residents. Fire Extinguishers found to be last charged on 02/07/2025 at the time of visit. Carbon Monoxide and smoke detectors were present and in order. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure in a cabinet closet next to the kitchen. LPA explained importance of having a signal system always in order. Administrator agreed that the facility will make sure all the exit doors has alarm in place and order all the time. Continued on LIC809-C... Continued from LIC809... At approximately 11:55PM, LPA reviewed 3 resident records and found 3 of 3 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 12:05PM, LPA reviewed 4 staff records. 4 of 4 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 current CPR & 1 st Aid certification. Administrator Certificate is for Nicolas Jethro #7033214740 expires 07/19/2026. 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 09/04/2025. 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 500 Personnel Summary LIC 610 Emergency Disaster Plan (If Changed) LIC 9020 Register of Facility Client’s/Resident’s 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 Licensee. Signature on form confirms receipt of documents.