Routine inspection·July 8, 2025

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 10 a.m. Upon arrival, LPA Mosley was greeted by staff and the Administrator and informed them of the visit. LPA met with Administrator, Maria R.E. Tanglao and the reason for the visit was explained. Entrance interview. The LPA 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. COMMON AREAS: The facility is a single-story structure with a large sun room, dining room and living room. At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 12:50 p.m., hardwire combination of smoke / carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 07/18/2024 and scheduled for service on 07/10/2025. The emergency telephone numbers are posted in common hallway. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 06/01/2025 and are conducted monthly. Activities were observed in the common areas. The fireplace in the living room was adequately screened. There is a functioning telephone on the premises. LPA did not observe any obstructions or hazards. KITCHEN: The LPA inspected the kitchen/food service area at 10:14 a.m. Knives and sharps were observed in a locked lock box in a bottom drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 119.4 degrees Fahrenheit at 10:15 a.m. REPORT CONTINUED ON LIC 809-C PAGE 2.. . (PAGE 2) REPORT CONTINUED FROM LIC 809... INTERVIEWS : Starting at 10:37 a.m. one (1) staff and five (5) resident interviews were conducted. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interview revealed that no concerns were noted or voiced at the time of the visit. BEDROOMS: There are five (5) total bedrooms in the facility; all bedrooms are designated as private, single occupancy, resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. No staff room. Licensee provided proof of 24 hour staffing. RESTROOMS: There are two in a half (2.5) restrooms. One in a half (1.5) are designated as shared / common restrooms and one (1) is designated as a private resident restroom. Resident restrooms were observed to be equipped with a nonslip surface. Grab bars were observed in the bathrooms. The restrooms were sufficiently stocked with supplies and paper towels. The water temperature was measured all resident restrooms and ranged between 113.9-114.1 degrees Fahrenheit, all within the required range. OUTDOOR SPACE: The LPA observed the back yard which had a shaded patio area with patio furniture including a table and chairs for resident use. The LPA observed one gate that self-latches with a clear passageway in case of an emergency. There are no bodies of water on the premises at the time of the visit. LPA observed a locked storage unit with supplies and outdoor equipment that remains locked at at all time. GARAGE : The garage is not accessible to residents. Laundry units, cleaning solutions, toxins, chemicals, and hazardous items are kept in the locked laundry room/ garage. There was a linen cabinet in the garage with extra towels and linens. Administrator's office is also set up in the garage. The garage is kept locked and inaccessible. RECORDS: Record review began at approx. 10:50 am . Resident Records were reviewed beginning at 10:50 a.m. and Personnel Records at 11:50 a.m. Five (5) 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 records were in order. Four (4) Personnel files including the Administrator’s file 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 in order. REPORT CONTINUED ON LIC 809-C PAGE 3... (PAGE 3) REPORT CONTINUED FROM LIC 809 PAGE 2... Infection Control / Emergency disaster planning : During today’s visit the LPA reviewed the facility’s infection control practices and the facilities emergency disaster plan. The facilities policies and procedures as it pertains to infection control and emergency planning are satisfactory. MEDICATIONS: Medications review began at approximately 2:15 p.m. The medications are in a locked medication closet adjacent to the kitchen. Medications for four (4) residents were reviewed. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. No errors observed during review. LPA obtained the following documents - Resident roster - LIC 9020, Staff roster - LIC 500, and a copy of the Limited Liability insurance. During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. Exit interview conducted. Copy of the report provided.