Routine inspection·September 4, 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 the Administrator. LPA met with The Administrator, Dvora "Debbie" Leventer 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 TV 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 12:20 p.m., hardwire combination of smoke / carbon monoxide detectors and fire doors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 11/07/2024. 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 07/11/2025 and are conducted quarterly. Activities were observed in the common areas. There is a functioning telephone on the premises. LPA observed surveillance cameras installed in the common areas of the facility however all are inactive and will remain inactive. INTERVIEWS : Starting at 10:28 a.m. and throughout the visit 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 interviews 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 10:26 a.m. Knives and sharps were observed in a locked drawer. 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 115.5 degrees Fahrenheit at 10:31 a.m. Cleaning supplies and other chemicals are kept in the locked laundry room and inaccessible to residents in care. 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 room is kept locked at all times and observed to be occupied by staff. All 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 seven (7) total restrooms. One (1) is designated as a staff / guest restroom, six (6) are designated as a private resident restrooms. 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 110.5-115.5 degrees Fahrenheit, all within the required range. LPA observed storage space closets in hallway containing extra clean linens and towels for resident use. LAUNDRY ROOM: LPA observed the locked laundry room adjacent to the main hallway. Laundry room has a washer and dryer and locked cleaning supplies. EXTERIOR : The exterior passageways were clean and clear of any obstructions. There is a covered patio area with tables and chairs for resident use located outside the front entrance. There are three (3) additional licensed facilities on the property. All four (4) facilities share a common recreation area with additional covered patio with furniture, and a putting green for resident use. There are no bodies of water noted on the premises. There is no front yard gate and the driveway gate is kept unlocked. GARAGE: The garage was observed to be locked and contain storage, a refrigerator and freezer, both containing extra food. Both were checked for proper labels and expiration dates. Report Continued on LIC 809-C PAGE 3 ... (PAGE 3) Report Continued from LIC 809-C PAGE 2... RECORDS: Record review began at approx. 10:50 a.m. Resident Records : were reviewed beginning at 11:00 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. All records were in order. Personnel Records were reviewed beginning at 11:40 a.m. 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. 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 criteria standard. MEDICATIONS: Medication review began at approximately 12:50 p.m. Medications are centrally stored and locked in a closet in the main hallway adjacent to the entrance to the home. 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 current 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.