Routine inspection·November 18, 2025

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 11:03AM. Upon arrival, LPA met with staff and Administrator Emma Carmona, and Licensee Irma Carmona who arrived at 12:05PM. Entrance interview conducted. At 11:05AM, 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. BEDROOMS: There are six (6) resident bedrooms. The LPA observed the resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedrooms were equipped with functional auditory exit alarms. There is a staff room on the ground floor that is accessed from outside. RESTROOMS: There are six (6) resident restrooms and one (1) staff/visitor bathroom in the hallway. Each bedroom has an attached restroom. LPA observed bathrooms to be clean, sanitary, and in operating condition with slip-resistant surfaces and grab bars. Hot water temperatures were measured in bathrooms and were between 109.4-113.0 degrees F, which is within the required range. KITCHEN: The LPA inspected the kitchen/food service area at 11:12AM. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility had a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for expiration dates and dates were clearly marked. Knives and sharps were observed locked and inaccessible in a drawer. (Report Continued on LIC 809C...) COMMON AREAS: At the time of the visit, living room and dining room furniture were observed to be in good condition. The facility maintained a comfortable temperature. At 11:27AM, smoke detector(s) and carbon monoxide detector were tested and were operational at the time of the visit. The fire extinguisher was observed fully charged and last serviced on 04/03/2025. Auditory exit alarms were functioning at the time of the visit. The washer and dryer are located in a closet next to Bedroom #1. LPA observed detergents and toxins in a locked cabinet above the washer and dryer. The LPA observed a closet with additional cleaning supplies and personal hygiene products locked and inaccessible to residents in care. OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for resident use. Emergency exits and passageways were observed free of obstruction. LPA observed side gate to self-latch. No bodies of water noted at the time of the visit. RECORD REVIEW: Beginning at 11:30AM, LPA reviewed five (5) out of five (5) resident files and three (3) personnel files for documents including but not limited to: medical records, care plans, resident Admission Agreement, TB test, health screening, staff training and fingerprint clearance. All resident and personnel files were in order. MEDICATION REVIEW: At 12:45PM, LPA reviewed medications for two (2) residents. Medications are centrally stored and locked in a cabinet by the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs were properly documented and logged. Medications were observed to be properly documented on the centrally stored medications and destruction record and were in compliance with regulation, state, and federal law. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency drills are conducted quarterly as required, with the last drill conducted on 10/23/2025. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.