Routine inspection·June 5, 2025

Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with Administrator Assistant Saif Ali and explained the reason for the visit. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. LPA inspected the kitchen/food service area at approx. 10:00 a.m. Knives and sharp objects are stored in a locked drawer left of the sink.  Some cleaning supplies were observed stored inaccessible underneath the sink. Kitchen appliances were observed  to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored at this time. Medication room was located next to the kitchen, medication and resident files were observed stored inaccessible to residents in care. At the time of the visit, the common area furniture's were observed to be in good condition.    The facility maintained a comfortable temperature of 72 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. LPA observed fire extinguishers to be fully charged and last serviced 02/05/2025. The LPA observed four(4) resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in each restroom between 105 - 120 degrees Fahrenheit. LPA observed hallway cabinets to store extra supply of linen. All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common areas. There is an attached garage observed inaccessible to residents in care.  LPA observed garage to store emergency food and emergency supplies. LPA also observed a laundry area, a sufficient supply  cleaning supplies securely stored, extra incontinent supplies, PPE , as well as additional furniture and medical equipment for facility use. The backyard has a covered outdoor area equipped with furniture including a table and chairs for resident use. The LPA observed one (1) self-latching gate with clear passageways clear of obstruction. There were no bodies of water over 3ft noted at the time of the visit. Records review, four (4) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Six  (6)  Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training.   All files were observed to be in order at this time . Last emergency disaster drill was conducted on May 30th , 2025. Medications review, medications are centrally stored in a locked cabinet adjacent to the kitchen.  All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRNs have physicians order on file. Medications are properly documented on the centrally stored medications and destruction record.  Medications appeared to be given as prescribed at the time of the visit. Infection control: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. The facility has an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate. The LPA obtained the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, a copy of the emergency disaster plan, and a copy of the facility’s liability insurance. Interviews were conducted during the visit. Exit interview conducted. A copy of the report was provided to the Administrator