Routine inspection·August 21, 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 Kemi Osilesi and explained the reason for the visit. The 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. The LPA inspected the kitchen/food service area at approx. 10:30 a.m.  LPA observed  (2) resident resting in the living room.  Knives and sharp objects are stored in a locked drawer to the left of the dishwasher. Cleaning supplies were observed kept underneath the sink inaccessible to residents in care. 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. At the time of the visit, the common area furniture's were observed to be in good condition. LPA observed multiple board games and activities stored on a book shelf in the living room. A sufficient supply of clean linen and towels were observed stored in the hallways next to Room #3. A sufficient supply of PPE and toiletries were observed stored inaccessible to residents in care in a closet next to room #1. 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 08/12/2025 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. At approx. 11:15 am, LPA observed staff conducting exercises with (2) residents. The staff room located to the right of the entry way  was observed to be inaccessible to residents in care and empty during the time of the visit. Office area was located to the right of entry way. 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 and extra perishable food. LPA also observed laundry area, along with additional furniture and medical equipment for facility use. Extra PPE supplies were observed stored in this area as well. 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 noted at the time of the visit. Records review, five (5) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Five (5) 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 08/15/2025. Medications review,  all medications reviewed including PRNs were labeled, stored and inaccessible to residents in care. Medications were observed to be administered as prescribed at this time. 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,  and a copy of the facility’s liability insurance. Interviews were conducted during the visit. Exit interview conducted and a copy of the report was provided.