Routine inspection·August 1, 2025

Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with staff and explained the reason for the visit. Administrator Norma Zanders arrived shortly after. 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. At approx 09:15 a.m.  The LPA inspected the kitchen/food service area.  Kitchen appliances appeared clean and to be in  operable condition at the time of the visit. At approx 09:30 a.m. LPA observed staff interacting with residents. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates. The knives and sharps were observed locked and inaccessible to residents in care. Medication cabinet was located next to the dining table. LPA observed it to be inaccessible to residents in care. LPA observed five (5) resident bedrooms , which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The resident 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. The hot water temperature was measured between 105 - 120 degrees Fahrenheit.  There was one (1) staff room, which was observed to be empty and inaccessible to residents in care during the time of the visit. 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 a hallway closet.  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 08/29/2024. There is an office area located next to living room. 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  laundry area next to attached garage entrance way. LPA observed laundry supplies  inaccessible to residents in care. There are (2) cabinets in this area, LPA observed it to store extra linen and an efficient amount of emergency food supplies. LPA observed garage to store, extra incontinent supplies, 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. LPA did not observe any bodies of water during the visit. There is a storage area located next to the kitchen. LPA observed it store extra supplies for facility use. LPA also observed an extra fridge with additional perishable food properly stored. Records review,  six (6) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Four (4)  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 files were observed to be in order at this time . Last emergency disaster drill was conducted on 07/2025. Medications review,  all medications including PRNs were labeled, stored and inaccessible to residents in care. Medications were observed to be administered as prescribed at this time. Infection control: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. The facility has an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate. 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. A copy of the report was provided to License