Routine inspection·September 18, 2025

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 10 a.m. Upon arrival, LPA Mosley was greeted by staff and Designee Elenor Jimenez who called the Administrator to inform them of the visit. The Licensee Representative, Dr. Rashita Aggarwal arrived shortly after and the reason for the visit was explained. Entrance interview. The LPA and staff / 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. COMMON AREAS: This includes the living room, and dining room. 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 12:40 p.m., hardwire combination of smoke / carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 11/04/2024. The emergency exiting plans/sketch are posted in every room. The emergency telephone numbers are posted in the common hallway. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 07/28/2025 and are conducted quarterly. Activities were observed in the common areas. The fireplace in the living room was adequately screened and non functional. There is a functioning telephone on the premises. INTERVIEWS : Starting at 10:10 a.m. one (1) staff and two (2) resident interviews were conducted. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interview revealed that no concerns were noted or voiced at the time of the visit. Report Continued on LIC 809-C PAGE 2 ... (PAGE 2) Report Continued from LIC 809-C... KITCHEN: The LPA inspected the kitchen/food service area at 10:20 a.m. Knives and sharps were observed in a locked pantry. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 110.1 degrees Fahrenheit at 10:21 a.m. Cleaning supplies and other chemicals are kept locked under the sink inaccessible to residents in care. BEDROOMS: There are six (6) total bedrooms in the facility; all six (6) bedrooms are designated as private, single occupancy, resident rooms. Three (3) out of six (6) resident rooms have exits to the exterior. All passageways were observed to be clear of obstructions. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. RESTROOMS : There are three (3) total restrooms. Two (2) are designated as a shared / common resident restroom, One (1) is designated as a private resident restroom. Resident restrooms were observed to be equipped with a slip resistant surface / mat. Grab bars were observed in the restrooms. The restrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in all resident restrooms and ranged between 105.6-119.1 degrees Fahrenheit, all within the required range. LPA made Licensee representative aware that the regulatory standard is 105-120 degrees Fahrenheit. LPA observed storage space closets in hallway containing extra clean linens and towels for resident use. LAUNDRY/GARAGE : The laundry area / attached garage is accessible through the kitchen adjacent to bedroom #1 and is kept locked at all times. LPA observed a washer and dryer along with laundry detergent and other chemicals that are stored inaccessible. LPA observed two staff lounge areas designated for staff use. BACKYARD: The entire property is fenced. The backyard has a covered patio area with shade, patio furniture including a table and chairs for resident use. LPA observed one (1) self-latching gate. There were no bodies of water noted at the time of the visit. Only 1 (one) pathway is used as an emergency exit which was free of obstructions at the time of the visit. Report Continued on LIC 809-C PAGE 3 ... (PAGE 3) Report Continued from LIC 809-C PAGE 2... RECORDS: Resident Records were reviewed beginning at 10:49 a.m. Five (5) 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, PRN authorization letters and current needs and services plan. All records were in order. Personnel Records were reviewed beginning at 11:35 a.m. five (5) 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. 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 they pertain to infection control and emergency planning, meet the regulatory standard. MEDICATIONS: Medication review began at approximately 12:10 p.m. Medications are centrally stored and locked in a cabinet located in the kitchen. 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: Documents obtained during the visit include: LIC 500 facility roster, LIC 9020A Resident roster and copy of the Limited Liability insurance. During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. Exit interview conducted. Copy of report reviewed and provided.