LPA Lee and HSD Flores toured the physical plant to evaluate compliance with health and safety requirements for residents in care. Areas inspected included, but were not limited to, the lobby, staff conference room, staff offices, medication room, kitchen, dining room, resident bedrooms and bathrooms, resident lounge, laundry room, and outdoor areas. LPA Lee inspected eleven resident rooms and observed that the rooms were equipped with the required furniture and sufficient lighting. A public telephone was available for resident use in the hallway near the dining room. The required postings were observed throughout the facility. The facility thermostat was observed between 70 to 74 degrees Fahrenheit throughout the facility, which is within the required range of 68 to 85 degrees Fahrenheit. Toxins were observed locked and inaccessible to residents. Sharp knives were observed inaccessible to residents. Medications were also observed to be properly secured and inaccessible to residents. Hot water temperatures were measured at the bathroom sinks in five resident rooms and ranged from 105.4 to 110.8 degrees Fahrenheit, which is within the required range of 105 to 120 degrees Fahrenheit.

CONTINUED LIC 809-C

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

Fire extinguishers were observed throughout the facility and were last inspected on 06/19/2026. Smoke and carbon monoxide detectors were observed throughout the facility. Smoke detectors were current and in compliance with fire safety requirements. The outdoor area was inspected and contained furniture available for resident use. Emergency walkways were unobstructed, and fences and gates were observed to be in good condition. The facility was observed to be clean, free of odors, and in good repair. Required furniture and sufficient lighting were observed throughout the facility.

LPA Lee reviewed 10 resident files. Records reviewed included, but were not limited to, Admission Agreements, Physician's Reports, Needs and Services Plans, Centrally Stored Medication Records, and ambulatory status documentation. Based on records reviewed it was learned that resident 1 (R1) did not have a TB test in the file, however the R1 does have an appointment scheduled for 08/21/2026 at 2:00 PM. LPA Lee also reviewed 11 staff files. Records reviewed included, but were not limited to, criminal background clearances, First Aid/CPR certifications, health screenings, and initial and ongoing training documentation. The records reviewed were observed to be complete.

LPA Lee reviewed the medications of 11 residents and found the medication records and medications to be current and complete. The facility’s first aid kit was also inspected and found to be complete. LPA Lee reviewed the facility's fire/disaster drill records, fire alarm system inspection report, and fire sprinkler system inspection and testing records. The facility conducts fire drills at least quarterly. The last documented fire drill was conducted on 05/24/2026. The fire alarm system was last inspected on 02/11/2026 and the fire sprinkler system was last inspected and tested on 02/11/2026.

On 06/15/2026, LPA Lee conducted a visit to the facility and toured nine resident rooms. During that visit, LPA Lee did not observe any live roaches or other insects in the resident rooms; however, one dead roach was observed in the hallway. LPA Lee also toured the kitchen and did not observe any live roaches. Multiple sticky pest traps were observed in the kitchen. HSD Flores stated that the facility experienced concerns with roaches in the kitchen during May 2026; however, the issue has since been addressed. HSD Flores stated that the facility contracts with Official Pest Prevention for pest control services. During May 2026, pest control services were conducted weekly and included treatment of the kitchen and placement of traps throughout the area.

LPA Lee reviewed the facility's pest control records and confirmed that pest control services have been provided from January 2026 to the present. Records indicated that routine pest control services were generally conducted twice per month, with services increased to weekly during May 2026 and continuing into June 2026 and resuming back to twice per month. During today's inspection, LPA Lee toured resident rooms, bathrooms, the dining room, and the kitchen and did not observe any live roaches in the facility. It was learned that the pest control company provided the facility with a monitoring device to detect and track any pest activity.

The following documents were provided to LPA Lee during today’s visit:

(1) LIC 308 Designation of Administrative Responsibility