Routine inspection·September 18, 2025

Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with Administrator Jennifer Fulgentes and explained the reason for the visit. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. LPA inspected the kitchen/food service area at approx. 09:35 a.m. The LPA observed resident watching television in the living room.  Knives and sharp objects are stored in a locked drawer to the right of the stove.   Kitchen appliances were observed to be in operable condition. At approx 09:50 a.m. LPA observed staff preparing food. The facility has a sufficient supply of perishable and non-perishable food properly stored at this time. Office area located in the kitchen. LPA observed medication centrally stored and resident files securely stored in this area as well. At the time of the visit, the common area furniture's were observed to be in good condition. A sufficient supply of clean linen and towels were observed stored in the hallways closet next to Room #3. The facility maintained a comfortable temperature of 72 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. LPA observed fire extinguishers to be fully charged and last serviced on 08/14/2025. The LPA observed four (4)  resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The  resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in each restroom between 105 - 120 degrees Fahrenheit. At approx. 10:50am, LPA observed staff interacting with residents with music. The staff room located next to the living room was observed to be inaccessible to residents in care and empty during the time of the visit. All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common areas. There is an attached garage observed inaccessible to residents in care. LPA observed garage to have an additional fridge to store extra perishable food. LPA also observed a laundry area, laundry supplies securely stored, extra incontinent supplies, linen, PPE , as well as additional furniture and medical equipment for facility use. The backyard has a covered outdoor area equipped with furniture including a table and chairs for resident use. The LPA observed two (2) self-latching gate with clear passageways clear of obstruction. There were no bodies of water noted at the time of the visit. Records review,  four (4) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Five (5)  Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training.  All records were observed to be in order at this time. Medications review: medications are centrally stored and locked inside a cabinet in the kitchen. All medications including PRNs were labeled, stored and locked inaccessible to individuals. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during medications review. During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Fire extinguisher was observed fully charged and last serviced 08/14/2025. Carbon monoxide detectors are wired and operational at the time of the visit. Emergency disaster drills conducted quarterly as per regulation; the last one conducted was a fire drill in August. LPA obtained the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, and facility’s liability insurance  Interviews were conducted during the visit. Exit interview conducted and copy of report provided.