Routine inspection·June 3, 2025

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA was greeted by staff who then contacted the Administrator telephonically and at this time, the reason for the visit was explained. The Administrator, Marilou Mallari arrived at the facility at approximately 10:10am. Entrance interview conducted. Starting at 10:15am, the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPA inspected the kitchen/food service area at 10:25am. Knives and sharps were observed locked and inaccessible in a kitchen cabinet. The LPA observed cleaning supplies under the kitchen sink locked and inaccessible to residents in care. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The LPA observed the fire extinguisher to be fully charged with a date of 08/28/2024. Required postings were observed throughout the common space. The LPA observed a fireplace adequately covered at the time of the visit. Report Continued on LIC 809C... Report Continued from LIC 809... Activities were observed in the living room and dining room. There is a working telephone on premises. The LPA observed a closet in the hallway with additional clean linens and towels. Auditory alarms were observed at the time of the visit. Night-lights were observed in all walkways. No obstructions or hazards observed inside or out. LAUNDRY ROOM: The LPA observed the laundry room locked and inaccessible to residents at the time of the visit. Laundry detergents and cleaning supplies were observed locked and inaccessible. Personal hygiene items were also observed locked and inaccessible to residents in care. RESTROOMS: There are four (4) restrooms for resident use. Bathrooms 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. Starting at 10:18am, the hot water temperature was measured in bathrooms, and they measured within te required range of 105 – 120 degrees Fahrenheit. BEDROOMS: There are five (5) bedrooms for resident use. One (1) bedroom is designated for double occupancy and four (4) bedrooms are designated for private / single occupancy. All resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPA observed a staff bedroom on premises. BACKYARD: The backyard has a covered patio area with patio furniture for resident use. The LPA observed two (2) locked sheds for storage purposes. All passageways were observed to be clear of any obstructions. There is one (1) side gate that self-latches. No bodies of water noted at the time of the visit. Report Continued on LIC 809C... Report Continued from LIC 809C... RECORDS: The LPA reviewed Resident Records and Personnel Records starting at 10:50am. Six (6) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All files were in order. Four (4) personnel files including the current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All records were in order. During today's visit, the LPA conducted interviews with one staff and three residents. No concerns noted. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and recently reviewed/updated. Emergency disaster drills conducted quarterly as per regulation; the last one was conducted on 04/02/2025. MEDICATIONS: Medications review began at approximately 12:40pm. Medications are centrally stored in a locked cabinet adjacent to the kitchen. PRN Authorization letters on file for all residents. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications appeared to be given as prescribed at the time of the visit. No citations issued. Exit interview conducted. A copy of the report was provided.