Routine inspection·July 11, 2025

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 9:35 a.m. Upon arrival, LPA Mosley was greeted by Mary Bernardo, House Manager who called the Administrator to inform them of the visit. The Administrator, Mirvat Yacoub arrived shortly after and the reason for the visit was explained. Entrance interview. LPA and staff 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: 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 10:20 a.m., hardwire combination of smoke / carbon monoxide detector and fire doors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 04/15/2025. The emergency telephone numbers are posted in common hallway. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 06/14/2025 and are conducted quarterly. Activities were observed in the common areas. The fireplace in the living room was adequately screened. There is a functioning telephone on the premises. There is a laundry room where cleaning supplies and disinfectants are kept locked in cabinets. The garage (converted into office space) is attached to the home and kept locked/inaccessible to others. Emergency food supplies, water and Personal Protection Equipment is stored in the garage/office space. Auditory alarms on all doors were functional at the time of the visit. Entry/exits were free of obstruction. Report Continued on LIC 809-C PAGE 2... (PAGE 2) Report Continued from LIC 809... INTERVIEWS : Throughout the visit starting at 9:49 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. BEDROOMS: There are seven (7) total bedrooms in the facility; four (4) bedrooms are designated as private, single occupancy, resident rooms, one (1) is designated as a shared, double occupancy, resident room and two (2) are designated as staff rooms. The staff rooms are kept locked at all times. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. RESTROOMS: There are six (6) total restrooms. Four (4) are designated as private resident restrooms, one (1) is designated as shared / common restrooms and one (1) is designated as a staff restroom. Resident restrooms were observed to be equipped with slip-resistant flooring. 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 108.0 - 109.8 degrees Fahrenheit, all within the required range. KITCHEN: The LPA inspected the kitchen/food service area at 9:57 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 108.1 degrees Fahrenheit at 9:58 a.m. Cleaning supplies and other chemicals are kept in a locked cabinet under the sink inaccessible to residents in care. BACKYARD: The entire property is fenced. The backyard has a portable umbrella for shade with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed two (2) self-latching gates. There were no bodies of water noted at the time of the visit. There are three (3) locked storage shed in the back yard inaccessible to residents. Report Continued on LIC 809-C PAGE 3... (PAGE 3) Report Continued from LIC 809-C PAGE 2... RECORDS: Record review began at approx. 10:06 a.m . Resident Records were reviewed beginning at 10:08 a.m. and Personnel Records at 10:53 a.m. Four (4) 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. Six (6) 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 LPA Mosley reviewed the facility’s infection control practices and emergency disaster plan. The facilities policies and procedures as they pertain to infection control and emergency preparedness are satisfactory. MEDICATIONS: Medications review began at approximately 12:06 p.m. The medications are stored adjacent to the kitchen, in the dining room, in locked cabinets. 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: LPA obtained the following documents during the visit: LIC 500 Facility roster, LIC 9020A Resident Roster, Current Liability Insurance, LIC 610E Emergency and Disaster Plan, and Food Menu. During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. Exit interview conducted. Copy of the report provided.