Routine inspection·September 25, 2025

Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with staff and explained the reason for the visit. Administrator Brenda Siapno  arrived shortly after. 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. 09:40 a.m. Knives and sharp objects are stored in a locked drawer to the right of the stove. No cleaning supplies were observed stored in the kitchen area. 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. Office area located in the kitchen. At the time of the visit, the common area furniture's were observed to be in good condition.  Medications and a sufficient supply of PPE and toiletries were observed stored inaccessible to residents in care in a closet at the entry way.   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 purchased in 05/01/2025. 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 various electronic equipment, flashlights and other supplies for emergency use. 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 an additional fridge to store extra perishable food. LPA also observed a laundry area, a sufficient supply of clean linen and towels, laundry supplies securely stored, extra incontinent supplies, PPE , canned goods, emergency food supply 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 two (2) self-latching gate with clear passageways clear of obstruction. There were no bodies of water over 3ft noted at the time of the visit. LPA observed a storage shed behind a locked gate that stored extra furniture and equipment for facility use. LPA also observed a small tool shed behind the locked gate that stored various gardening tools. Records review began:  six (6) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Four (4)  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 . Medications review: medications are centrally stored and locked inside an entry way closet. All medications including PRNs were labeled, stored and locked inaccessible to individuals. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during medications review at this time. 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 at this time. Smoke detectors were tested and all functional at the time of the visit.  Carbon monoxide detectors are wired and operational at the time of the visit. Emergency disaster drills conducted quarterly as per regulation; the last one conducted was a fire drill on 08/05/2025. LPA obtained the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, and facility’s liability insurance  Interview conducted during the visit. Exit interview conducted. A copy of the report was provided to the Administrator