Routine inspection·July 17, 2025

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 9:30 a.m. Upon arrival, LPA Mosley was greeted by staff who called the Administrator to inform them of the visit. The Administrator, Marisol Flamenco arrived shortly after and the reason for the visit was explained. Entrance interview. The LPA and 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: 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 10:11 a.m., hardwire combination of smoke / carbon monoxide detector and fire doors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 07/22/2024 with a new one purchased on 07/17/2025.The emergency exiting plans/sketch are posted in every room. 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 05/13/2025 and are conducted quarterly. Activities were observed in the common areas. The fireplace in the living room was adequately screened. INTERVIEWS : Starting at 9:50 a.m. LPA conducted one (1) staff and two (2) resident interviews. Staff interview 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... (PAGE 2) Report Continued from LIC 809... BEDROOMS: There are six (6) total bedrooms in the facility; all six (6) 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. BATHROOMS: There are five (5) bathrooms. Three (3) are designated as shared / common bathrooms and two (2) are designated as private resident bathrooms. Resident bathrooms were observed to be equipped with slip resistant flooring / mats. Grab bars were observed in the bathrooms. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured all resident bathrooms and ranged between 105-120 degrees Fahrenheit, all within the required range. KITCHEN: The LPA inspected the kitchen/food service area at 10:05 a.m. Knives and sharps were observed in a locked cabinet. 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 110.1 degrees Fahrenheit at 10:07 a.m. Cleaning supplies and other chemicals are kept locked in the garage inaccessible to residents in care. LPA observed an adequate amount of emergency food and water. The garage door is accessible through the kitchen and kept locked at all times. Adjacent to the garage door entrance is where the medication cart is located. BACKYARD: The entire property is fenced. The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. All passageways were observed to be clear. LPA observed one (1) self-latching gate. There were no bodies of water noted at the time of the visit. GARAGE: The garage is accessible through the kitchen and kept locked at all times. The garage contains an additional refrigerator and freezer with perishable food items that were checked for proper labels and expiration dates . Additional nonperishable food was observed along with emergency food and water. Cleaning supplies and disinfectants are stored in the locked garage. The laundry area is located in the locked garage. All laundry supplies are locked and inaccessible to residents in care. Report Continued on LIC 809-C PAGE 3... (PAGE 3) Report Continued from LIC 809-C 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. RECORDS: Record review began at approx. 10:15 a.m. Resident Records were reviewed beginning at 10:15 a.m. and Personnel Records at 11:40 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 and PRN Authorization letters. Two (2) 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. MEDICATIONS: Medications review began at approximately 12:53 p.m. The medications are in a locked medication cart adjacent to the 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. DOCUMENTS: LPA obtained the following documents - Resident Roster - LIC 9020, Staff Roster - LIC 500, a copy of the Limited Liability insurance, and LIC-9282 Infection Control Plan. No deficiencies were cited during today’s inspection. Exit interview conducted. A copy of the report was provided.