Routine inspection·February 3, 2026

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct the required annual visit today at 09:05 a.m. Upon arrival, there were three (3) staff and four (4) residents present. The LPA was greeted by staff who then contacted the Administrator telephonically. The Administrator, Oskar Arcenas arrived at approximately 10:05 a.m. and the reason for the visit was explained. Entrance interview conducted. Infection Control / Emergency Disaster Planning: The LPA reviewed the facility's infection control plan at approximately 09:15 a.m. The facility’s policies and procedures as they pertain to infection control are adequate. The LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and recently reviewed/updated. Emergency disaster drills conducted quarterly as per regulation; last drill conducted on 01/04/2026. Beginning at 10:15 a.m., the LPA along with the 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. The following was observed: Kitchen: The LPA inspected the kitchen/food service area at approximately 10:20 a.m. Knives and sharps were observed in a kitchen drawer locked and inaccessible. Cleaning supplies were observed locked and inaccessible under the kitchen sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. Report Continued on LIC 9099C... Report Continued from LIC 9099... 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. The LPA observed a fire extinguisher to be fully charged with a date of 06/13/2025. Required postings were observed throughout the common space. There is a working telephone on premises. Camera observed in the common areas. The LPA observed a fireplace in the living room adequately screened at the time of the visit. Activities were observed in the living room. Auditory alarms were observed functioning at the time of the visit. At 10:15 a.m., the smoke detector, carbon monoxide, and fire door were tested and operational at the time of the visit. No hazards/obstructions observed inside or out. Restrooms: There are two (2) restrooms for residents’ use. Bathrooms 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. Starting at 10:11 a.m., the hot water temperature was measured in bathrooms, and they measured within the required range of 105 – 120 degrees Fahrenheit. Personal hygiene items were observed locked and inaccessible to residents at the time of the visit. Bedrooms: There are four (4) bedrooms for residents’ use. Bedrooms are designated as private / single bedrooms. Bedrooms were observed to be furnished appropriately and had sufficient lighting. Additional clean linens and towels were observed in a closet by the hallway. Staff bedroom was observed locked and inaccessible at the time of the visit. Garage/Laundry Room: The garage was inaccessible to residents in care at the time of the visit. There is a second refrigerator with additional food for both residents and staff. The LPA observed an adequate amount of emergency food and water. A sufficient supply of Personal Protection Equipment (PPE) was observed. Washer and dryer are kept locked at all times. Cleaning supplies and detergents were observed locked and inaccessible at the time of the visit. Report Continued on LIC 9099C... Report Continued from LIC 9099C... Outdoors: The backyard has a covered patio area with adequate furniture for residents’ use. Emergency passageway was observed to be clear of any obstructions. There is one (1) side gate with latching mechanisms. No bodies of water noted at the time of the visit. Records: Record review began at approximately 10:25 a.m. Four (4) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, consent for treatment form, and current needs and services plan/IPP. All files were in order. Four (4) personnel files including the current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments with negative TB test results, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All personnel files were complete. The Administrator’s Certificate is valid until 02/20/2028. During today’s visit, the LPA interviewed one staff member and one resident. No concerns were reported. Medications: Medications review began at approximately 11:40 a.m. Medications are centrally stored and kept in a locked closet by the main hallway. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications are properly documented on the centrally stored medication and destruction record. Medications appear to be administered as prescribed at the time of the visit. No citations issued. Exit interview conducted. A copy of the report was issued.