Routine inspection·January 23, 2026

Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit at 9:30am. Upon arrival LPA met with staff and explained the reason for the visit. Licensee  Norma Zanders arrived shortly after. At approx. 09:45am, LPA 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. Facility is a single-story residence and consists of a total of five (5) bedrooms and two (2) bathrooms.  During physical plant tour LPA observed the required postings throughout the facility. The kitchen appeared to be clean and the appliances and fixtures functional during the time of visit.  LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects are stored underneath the sink no cleaning supplies or products were observed stored in this area.  There was a staff room next to the kitchen. LPA observed it inaccessible to residents in care and empty at the time of the visit. The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Hallway closest near Room #4 was observed to be to store a sufficient supply of linen. LPA observed bathrooms to be clean, properly supplied and had functional fixtures. LPA observed non-skid mats. The hot water was measured in each bathroom between 105 - 120 degrees Fahrenheit. Laundry area located next to bedroom #3. LPA observed cleaning supplies and detergent inaccessible to residents in care. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Medications are stored in a locked cabinet next to the television. LPA observed it to be inaccessible to residents in care. There is a dedicated area for the posting of required documents located in the sunken living room in the office area. There is a fireplace  that is non-operable at this time. It is screened and there are no tools. LPA observed appropriate signage regarding infection control posted throughout the facility. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detectors were operational at the time of the visit. Fire extinguishers were observed fully charged and last serviced July 29, 2025.  The exterior passageways were clean and clear of any obstructions. The entire property is not fenced. The back and sides of the house are separated from the front yard by gates at the east and west side passageways. The gates in the backyard has a self-latching mechanism for persons to exit the backyard.  LPA observed appropriate furniture for outdoor use. There is an attached garage that is only accessible from the exterior of the home. LPA observed it to be used as a storage area at this time. LPA observed a 30 day supply of PPE, incontinent supplies, extra perishable food stored in the an extra fridge and freezer along with a 30 day emergency food supply. Records review, six (6) client records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Six (6)  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 . Medication review, medications for all residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. Infection control / Emergency Disaster plan: 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 it pertains to infection control are adequate. Emergency disaster drills are to be conducted quarterly; the facility’s last emergency disaster drill was conducted on 01/15/2026. 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 administrator. Smoke detectors and carbon monoxide detectors were tested, all alarms were functional at the time of the visit. During today’s visit LPA obtained a copy of the facility’s LIC 500 and resident roster. Exit interview conducted and copy of the report was issued.