Routine inspection·February 5, 2026

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct the required annual visit today at 09:45 a.m. Upon arrival, there were two (2) staff and three (3) residents present. The LPA met with Administrator, Susan Lumbres and explained the reason for the visit. Entrance interview conducted. Beginning at 09:50 a.m., 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. The following was observed: Kitchen: The LPA inspected the kitchen/food service area at approximately 10:10 a.m. Knives and sharps were observed in a kitchen drawer locked and inaccessible. Cleaning supplies were observed in a locked cabinet at the time of the visit. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. 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. The LPA observed a fire extinguisher to be new with a purchase date of 12/28/2025. Required postings were observed throughout the common space. There is a working telephone on premises. Fireplace was observed adequately covered. Report Continued on LIC 9099C... Report Continued from LIC 9099... Activities were observed in the living room. Auditory alarms were observed functioning at the time of the visit. At 10:14 a.m., the smoke detector and carbon monoxide were tested and operational at the time of the visit. The LPA observed an adequate amount of emergency food and water. The LPA observed a washer and dryer. Cleaning supplies and detergents were observed locked and inaccessible at the time of the visit. No hazards/obstructions observed inside or out. Restrooms: There are three (3) restrooms for residents use. Bathrooms 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. Starting at 09:58 a.m., the hot water temperature was measured in bathrooms, and they measured within the required range of 105 – 120 degrees Fahrenheit. Bedrooms: There are five (5) bedrooms for residents use. Four (4) bedrooms are designated as private / single bedrooms, and one (1) bedroom is designated as shared / double occupancy. Bedrooms were observed to be furnished appropriately and had sufficient lighting. Additional clean linens and towels were observed in a closet by the hallway. Staff bedroom was observed locked and inaccessible at the time of the visit. Outdoors: The backyard has a covered patio area with adequate furniture for residents’ use. Emergency passageway was observed to be clear of any obstructions. The LPA observed two (2) sheds for storage purposes. There is one (1) side gate with latching mechanisms. No bodies of water noted at the time of the visit. Records: Record review began at approximately 10:20 a.m. Three (3) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, consent for treatment form, and current needs and services plan. All files were in order. Report Continued on LIC 9099C... Report Continued from LIC 9099C... Three (3) personnel files including the current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments with negative TB test results, criminal record clearances, first aid, and the appropriate yearly training. All personnel files were complete. The Administrator’s Certificate is valid until 12/20/2026. Infection Control / Emergency Disaster Planning: The LPA reviewed the facility's infection control plan during today’s visit. The facility’s policies and procedures as they pertain to infection control are adequate. The LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and recently reviewed/updated. Emergency disaster drills conducted quarterly as per regulation; last drill conducted on 01/05/2026. Medications: Medications review began at approximately 12:05 p.m. Medications are centrally stored in a locked cabinet adjacent to the living room. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications are properly documented on the centrally stored medication and destruction record. Medications appear to be administered as prescribed at the time of the visit. No citations issued. Exit interview conducted. A copy of the report was issued.