Routine inspection·June 13, 2025

Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required Inspection and met with Licensee Dharmistha Patel. There are residents receiving hospice services. Required postings were observed. Fees are current. Contact information was reviewed. LPA/Licensee toured the facility, passageways were free from obstructions, temperature measured 70 degrees F, residents' rooms appeared furnished per regulation. Hot water measured 108.5, 114.8 and 106.3 degrees F which is within range of 105-120 degrees F. Grab bars observed in toilet/shower areas. Extra hygiene products and linens were available. Carbon monoxide detector and smoke detectors were checked and were operational. Fire extinguishers were charged and inspected on March, 2025. Last Disaster Drill was conducted on April 4, 2025. Facility has at least two days of perishable and one week of non-perishable foods. Medications centrally stored in kitchen drawers. Items that could pose a risk to residents along with disinfectants, cleaning solutions are maintained locked in a closet located in the kitchen. Auditory alarms on exit doors were operational. File Review was initiated at 10:00am. Five resident and three staff files were reviewed. All residents have current medical assessments and appraisal/needs and services plans. Staff have required First Aid and CPR certificates and training hours completed. Administrator Dharmistha Patel 7009824740 expires 1/8/2027. Medication and medication records were reviewed. Continues on LIC809C... Continued from LIC809... During last annual LPA had a discussion with Licensee due to bedrooms were labeled differently as stated in their fire clearance, which are not the same locations indicated on their fire clearance approved on 5/27/2016. Based on LPA's records review it was determined that the Licensee submitted some documentation, but process was not completed timely to correct labeling discrepancy. Today, Licensee agreed to submit pertinent documentation to the Department to have the Fire Inspector to revise current fire clearance and rooms, because they need to clarify which rooms could eventually be used for bedridden residents if needed. LPA/Licensee discussed Dementia regulation changes and provided resources including LIC602A form for their review. Licensee agreed to submit updates of the following documents by 6/27/2025: - Designation of Administrative Responsibility (LIC308) - Personnel Report (LIC500) was already submitted to the Department prior to this visit. - Emergency Disaster Plan (LIC610E if there are any changes) - Control of property (Lease agreement). - Liability insurance was already submitted to the Department prior to this visit. No deficiencies were cited during today's inspection. Exit interview was conducted with Licensee and a copy of this report was given.