Post-licensing visit·October 3, 2025

At approximately 10:30am, Licensing Program Analyst (LPA) Contreras arrived unannounced to conduct a post-licensing visit and was greeted by designee Mary Grace Defeo: Care Coordinator. Post licensing is being conducted after a change of ownership. Facility is an Adult Residential Care For the Elderly with a fire clearance approved for 6 non-ambulatory, 1 can be bedridden in room #4 and a hospice waiver for 5 residents. There are currently 6 residents in care. LPA toured all buildings and grounds and all were found clear from obstruction. Facility was found to be at a comfortable temperature. All required postings were visible. LPA observed there to be an incontinence smell throughout 2 out of 4 rooms. LPA had conversation with admin that keeps must be kept clean and free of odors at all times, (technical violation issued). There was a sufficient supply of nonperishable foods as required by Title 22 Regulations with expiration dates noted. LPA observed there to not be enough perishable food supply for 2 days for 6 residents, (technical violation issued) . Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for all facility sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility's fire extinguisher was observed to be charged and last inspected on 5/04/2025. Smoke and carbon monoxide detectors were tested and operational. Disaster drill last conducted in 4/10/25. LPA had conversation with admin that disaster drills must be conducted quarterly, (technical violation issued). Continued onto 809C.... Continued from 809.... LPA conducted a file review for 3 residents, all files were up to date. Awaiting new admissions agreements for 2 residents under new license. LPA conducted 3 staff file reviews, all files were up to date. Staff due for 20 hour annual training, admin stated staff is already signed up for training. Admin to send copies of 20 hours annual training certificates for all 3 staff once completed by 10/31/25 (advisory issued). Failure to comply may face potential citations from CCL.**** LPA conducted medication spot check with admin and found all medication to be secure with Centrally Stored Log up to date. LPA retrieved the following forms during visit: - Liability Insurance ( exp.11/06/2025) - LIC308: Designation of Responsibility - LIC500: Personnel Report No deficiencies cited during todays visit. Exit interview conducted. Copy of report and LIC9102 (Technical Advisories) discussed and provided to Licensee. Signature on form confirms receipt of documents.