Routine inspection·December 4, 2025

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 12:31 PM. LPA met with facility staff who contacted the facility Co-Administrator Jovilito Gagarin. The Co-Administrator arrived to the facility at approximately 12:45 PM. Entrance interview was conducted and the reason for the visit was explained. Beginning at approximately 12:45 PM the LPA, along with the Co-Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: OUTDOOR SPACE/GARAGE: The facility has one (1) emergency exit gate located on the side of the home; LPA observed clear passageways for emergency exit use. The facility had adequate shaded seating outdoors for resident use. LPA observed the garage to contain extra oxygen supplies, care supplies, emergency water supplies, and an extra fridge/freezer. LPA observed the garage’s entrance to the interior of the facility to be locked and inaccessible to clients in care. KITCHEN : The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured under-sink cabinet to contain cleaning chemicals and a secured drawer to contain knives and other sharp objects. Continued on LIC 809C. COMMON AREAS : This included the living room, hallway, office, and dining area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contained an appropriately screened fireplace and activities for resident use. LPA observed a camera located in the living room LPA confirmed with the Co-Administrator that audio is not recorded. The hallway was observed to be clean and free from any obstructions. The hallway included a closet which contained the facility’s washer and dryer and a locked storage cabinet which contained laundry and cleaning chemicals. Additionally, the hallway contained storage cabinets which contained extra linens for resident use. The office was observed to be locked and inaccessible to clients in care and contained resident/facility files. The dining area was observed to be equipped with adequate seating for resident use. The dining area/living room contained all required postings. LPA observed the dining area to contain a wall mounted fire extinguisher that was fully charged and serviced on 11/05/2025. The facility’s combination fire and carbon monoxide alarms were tested at 01:40 PM and were functional at the time of the visit. All exits in the facility were observed to contain functioning auditory alarms. BEDROOMS : There are four (4) bedrooms in the facility; two (2) are dual occupancy and two (2) are single occupancy resident rooms. LPA and the facility Co-Administrator toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. BATHROOMS : There are two (2) bathrooms at the facility. One (1) is designated as a shared/common resident bathroom and one (1) is a private resident bathroom. Both resident bathrooms were observed to be clean and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured to be between 113.5 and 117.3 degrees Fahrenheit, which is in compliance with regulation. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 10/02/2025. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Co-Administrator. Continued on LIC 809C. INTERVIEWS: LPA interviewed one (1) resident. The resident interviewed stated that the staff treat them well and are attentive to their needs. The resident interviewed had no concerns with the facility. LPA interviewed one (1) staff member. The staff member interviewed was knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse Due to time constraints LPA will return at a later date to conduct file review, medication review, and to collect copies of pertinent documentation. No deficiencies were observed during today’s inspection. Exit interview conducted and copy of the report was issued.