Routine inspection·December 4, 2025

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 9:55 a.m. Upon arrival, LPA Mosley was greeted by staff who called the Administrator to inform them of the visit. The Administrator / Licensee Representative, Roxana Lara arrived shortly after and the reason for the visit was explained. Entrance interview. The LPA and staff / 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. COMMON AREAS: This includes the living room, and dining 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 10:45 a.m. hardwire combination of smoke / carbon monoxide detectors and fire doors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 09/19/2025. The emergency exiting plans/sketch are posted. The emergency telephone numbers are posted in the common hallway. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 09/19/2025 and are conducted quarterly. Activities were observed in the common areas. There is a functioning telephone on the premises. Auditory alarms at the entrances and exits were observed and functional at the time of the visit. LPA observed surveillance cameras installed in the common areas of the facility. The Administrator presented the live monitoring screen to the LPA, confirming that all cameras were functioning properly and that none of them were equipped with audio capability. INTERVIEWS : Starting at 9:58 a.m. and throughout the visit two (2) staff and two (2) resident interviews were conducted. Staff interviews revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interviews revealed that no concerns were noted or voiced at the time of the visit. Report Continued on LIC 809-C PAGE 2 ... Report Continued on LIC 809-C PAGE 2 ... BEDROOMS: There are five (5) total bedrooms in the facility; four (4) bedrooms are designated as private, single occupancy, resident rooms and one (1) shared, double occupancy resident room. There is no staff room and Administrator stated that staff remain awake at night. Two (2) out of five (5) resident rooms have exits to the exterior. All passageways were observed to be clear of obstructions. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. RESTROOMS : There are three (3) total restrooms. Two (2) are designated as a shared / common resident restrooms, and One (1) is designated as a private resident restroom. Resident restrooms were observed to be equipped with a slip resistant surface / mat. Grab bars were observed in the restrooms. The restrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in all resident restrooms and ranged between 105.6-117.3 degrees Fahrenheit, all within the required range. LPA observed storage space closets in the hallway containing extra clean linens and towels for resident use. KITCHEN: The LPA inspected the kitchen/food service area at 10:33 a.m. Knives and sharps were observed in a locked 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 117.3 degrees Fahrenheit. Cleaning supplies and other chemicals are kept locked under the sink and in the garage inaccessible to residents in care. BACKYARD: The entire property is fenced. The backyard has a patio area with an umbrella for shade, patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed two (2) self-latching gates. There is a gated in the ground pool that was locked and inaccessible at the time of the visit. There is a locked storage shed in the back yard inaccessible to residents. Both pathways are used as an emergency exit which were free of obstructions at the time of the visit. GARAGE / LAUNDRY ROOM: LPA observed the facility garage, which was locked and contained the laundry units- washer and dryer, emergency food and water, a storage room containing emergency supplies, and general supplies. Report Continued on LIC 809-C PAGE 3 ... (PAGE 3) Report Continued from LIC 809-C PAGE 2... MEDICATIONS: Medication review began at approximately 10:47 a.m. Medications are centrally stored and locked in a closet adjacent to the entrance and kitchen. Medications for three (3) 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 observed the first aid supplies to be complete, including a thermometer and a current version of a first aid manual. RECORDS: Resident Records: were reviewed beginning at 11:05 a.m. 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, current needs and services plan, Hospice records and Home Health records. All records were in order. Personnel Records were reviewed beginning at 12:15 p.m. five (5) 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. INFECTION CONTROL/ EMERGENCY DISASTER PLANNING: During today’s visit the LPA reviewed the facility’s infection control practices and the facilities emergency disaster plan. Both documents were observed to be complete and updated annually as required. The facilities policies and procedures, as they pertain to infection control and emergency planning meet the regulatory standard. DOCUMENTS: Documents obtained during the visit include: LIC 500 facility roster, LIC 9020A Resident roster and copy of the current Limited Liability insurance. During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. Exit interview conducted. Copy of report reviewed and provided.