Routine inspection·July 16, 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, Karen Rosales arrived shortly after and the reason for the visit was explained. Entrance interview. INTERVIEWS : Starting at 9:40 a.m. two (2) 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. 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. BEDROOMS: There are seven (7) total bedrooms in the facility; six (6) bedrooms are designated as private, single occupancy, resident rooms and one (1) staff room. The staff rooms are kept locked at all times. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. During todays visit LPA observed an additional resident bedroom that was addressed in last years annual inspection detailing that they added a dry wall in the living room that created an additional bedroom after licensure. The Administrator presented evidence that the LIC200 form and the revised facility sketch reflecting the addition were submitted to CCLD on July 15, 2024, at 9:56 p.m. Report Continued on LIC 809-C PAGE 2... (PAGE 2) Report Continued from LIC 809... RESTROOMS: There are four (4) restrooms. Two (2) are designated as shared / common restrooms, one is designated at private resident restroom, and one (1) is designated as a staff restroom. Resident restrooms were observed to be equipped with slip resistant flooring. Grab bars were observed in the restrooms. The restrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured all resident restrooms and ranged between 109.6-112.5 degrees Fahrenheit, all within the required range LAUNDRY : The laundry area, with a washer and dryer is behind the kitchen area, directly across from the designated staff room. Laundry detergent and chemicals are stored inaccessible in a large cabinet to the right of the washer and dryer. LPA observed an adequate amount of emergency water. KITCHEN: The LPA inspected the kitchen/food service area at 10:13 a.m. Knives and sharps were observed in a locked cabinet under the sink along with cleaning solutions and other chemicals. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Two (2) refrigerators and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 106.7 degrees Fahrenheit at 10:14 a.m. Cleaning supplies and other chemicals are kept in a locked cabinet under the sink inaccessible to residents in care. LPA observed an adequate amount of emergency food and water. LPA observed medications to be in a locked cabinet in the kitchen to the left upon entry from the main home entrance. 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 12:18 p.m., hardwire combination of smoke / carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 05/20/2025. 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 07/14/2025 and are conducted quarterly. Activities were observed in the common areas. There is a functioning telephone on the premises. Report Continued on LIC 809-C PAGE 3... (PAGE 3) Report Continued from LIC 809-C PAGE 2... BACKYARD/GARAGE: 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. There is a locked storage shed in the back yard inaccessible to residents. The garage is not accessible to residents. 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. 10:22 a.m. Resident Records were reviewed beginning at 10:22 a.m. and Personnel Records at 11:27 a.m. Six (6) 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. Four (4) 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 12:20 p.m. Medications are in a locked cabinet in the kitchen to the left upon entry from the main home entrance. Medications for four (4) 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, Application - LIC 200, Updated Facility Sketch, Plan of Correction (POC) for 87202 (a)(2), 87305 (a), and forwarded email with POC from 07/12/2024 visit. No deficiencies were cited during today’s inspection. Exit interview conducted. A copy of the report was provided.