Routine inspection·July 10, 2025

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 10:15 a.m. Upon arrival, LPA Mosley was greeted by staff / house manager Tiffany Lara who called the Administrator to inform them of the visit. The Administrator, Roxana Lara arrived shortly after and the reason for the visit was explained. Entrance interview. The LPA and house manager 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 12:36 p.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 07/09/2025. 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 06/20/2025 and are conducted quarterly. Activities were observed in the common areas. The fireplace in the living room was adequately screened. LPA observed a locked storage closet adjacent to the entrance with an adequate amount of emergency supplies. There is a functioning telephone on the premises. BEDROOMS: There are seven (7) total bedrooms in the facility; of which six (6) bedrooms are designated as private, single occupancy, resident rooms and one (1) staff room. The staff room is kept locked at all times. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Report Continued on LIC 809-C PAGE 2... (PAGE 2) Report Continued from LIC 809... RESTROOMS: There are three (3) restrooms. One (1) is designated as shared / common bathroom, one (1) is designated as a private resident bathroom and one (1) is designated as a staff bathroom. Resident restrooms were observed to be equipped with a slip-resistant 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 105.1 -105.6 degrees Fahrenheit, all within the required range. GARAGE : The entry to the garage was observed to be locked and inaccessible to residents. The garage was observed to contain a washer and dryer, laundry supplies and chemicals are stored in the garage along with various cleaning supplies. Garage contained adequate emergency food and water supplies. LPA observed an extra refrigerator with food that was checked for proper labels and expiration dates. KITCHEN: The LPA inspected the kitchen/food service area at 10:28 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 106.1 degrees Fahrenheit at 10:30 a.m. Cleaning supplies and other chemicals are kept in a locked cabinet inaccessible to residents in care. OUTDOOR SPACE: The backyard has sufficient patio furniture including shaded tables and chairs for resident use. One outdoor shed was observed to contain extra care supplies. Facility has two exit gates that were observed to self-latch, LPA observed clear passageways for emergency exit use. RECORDS: Record review began at approx. 10:49 a.m . Resident Records were reviewed beginning at 10:51 a.m. and Personnel Records at 11:52 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. Six (6) 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 from LIC 809-C PAGE 3... (PAGE 3) Report Continued from LIC 809-C PAGE 2... INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit LPA Mosley reviewed the facility’s infection control practices and emergency disaster plan. The facilities policies and procedures as they pertain to infection control and emergency preparedness are satisfactory. INTERVIEWS : Throughout the visit, starting at 10:40 a.m one (1) staff and three (3) resident interviews were conducted. 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. MEDICATIONS: Medications review began at approximately 1:15 p.m. The medications are in a locked cabinet area adjacent to the kitchen. Medications for three (3) of five (5) 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 obtained during the visit include: LIC 500 facility roster, LIC 9020A Resident roster, and current 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.