Routine inspection·January 13, 2026

Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with the 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. 10:30 a.m. There is a gate impeding access to the kitchen however LPA observed residents able to access kitchen by opening gate without staff assistance.  Knives and sharp objects are stored in a locked drawer to the right of the stove. Some cleaning supplies were observed kept underneath the sink inaccessible to residents in care. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored at this time. 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 Aug 15, 2025. Various activities were observed stored in the front room by entrance. The LPA observed four (4)  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. LPA observed medication to be centrally stored and inaccessible in a cabinet next to bedroom #1. LPA observed the 2nd story of the facility to be for staff use only and inaccessible to residents in care. 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 a laundry area and to store, 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. LPA observed a swimming pool with a six-foot fence inaccessible to residents in care. Records review, five (5) client 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 . Medication review, medications for all residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. Infection control / Emergency Disaster plan: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are to be conducted quarterly; the facility’s last emergency disaster drill was conducted on 01/05/2026. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s administrator. Smoke detectors and carbon monoxide detectors were tested, all alarms were functional at the time of the visit. During today’s visit LPA obtained a copy of the facility’s LIC 500 and resident roster. Exit interview conducted and copy of the report was issued.