Most inspections found no deficiencies, with the facility generally clean, well-maintained, and compliant with infection control and safety standards. The most recent report from May 30, 2025, was perfect with no deficiencies noted. Earlier reports included a substantiated complaint in June 2023 where the facility failed to provide a required refund for pre-admission fees, and a deficiency in June 2024 related to an outdated medical assessment for a resident with dementia. Other issues were minor or isolated, and several complaint investigations were unsubstantiated. The facility appears to have maintained good compliance overall, with some improvement seen in the most recent inspection.
The visit was an unannounced required annual inspection conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements.
Findings
The facility was found to be clean, well-maintained, and in compliance with all applicable regulations. No deficiencies were observed or cited during the inspection. Infection control practices were adequate, and all safety and operational standards were met.
Report Facts
Residents receiving hospice care: 1Fire extinguishers: 2Food supply duration: 3Food supply duration: 7Administrator certificate expiration: 2026Licensing fees due date: 2025Water temperature: 105.9Water temperature: 107.5Water temperature: 106.7Last fire inspection date: Apr 22, 2025Last emergency drill date: Mar 10, 2025Emergency and Disaster Plan update date: May 25, 2025Liability insurance expiration: Dec 29, 2025
Employees Mentioned
Name
Title
Context
Wendy Gibbs
Licensing Program Analyst
Conducted the inspection and authored the report.
Arlene Feliciano
Administrator
Facility administrator met during inspection and participated in exit interview.
The inspection was an unannounced annual required visit conducted to evaluate the facility's compliance with licensing regulations using the CARE Inspection Tool.
Findings
The facility was found to be sanitary, appropriately furnished, and compliant with infection control practices. However, a deficiency was noted where a resident diagnosed with dementia did not have a current medical assessment and appraisal, with the last assessment dated 2019.
Deficiencies (1)
Description
Resident diagnosed with dementia (R1) does not have a current medical and appraisal assessment; last assessment was in 2019.
Report Facts
Capacity: 6Census: 5PPE supply: 30Water temperature: 105.6Facility temperature: 73Fine amount: 100POC due date: Jun 28, 2024
Employees Mentioned
Name
Title
Context
Ernand Dabuet
Licensing Program Analyst
Conducted the inspection and authored the report
Janae Hammond
Licensing Program Manager
Supervisor of the inspection
Arlene Feliciano
Administrator
Facility administrator met during inspection and involved in exit interview
An unannounced 1-year annual inspection visit was conducted to evaluate compliance with licensing requirements for the Residential Care Facility for the Elderly.
Findings
The facility was found to be sanitary, appropriately furnished, and in compliance with regulations. No deficiencies were cited during the inspection.
Report Facts
Fire extinguishers: 2Water temperature: 113.5Facility temperature: 75
Employees Mentioned
Name
Title
Context
David España
Licensing Program Analyst
Conducted the inspection and met with the administrator.
Arlene Feliciano
Administrator
Facility administrator who assisted with the inspection.
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-01-11 regarding the facility staff not issuing a proper refund.
Findings
The investigation found that the facility administrator admitted a refund was not provided to the responsible party for pre-admission fees. The allegation was substantiated based on interviews and record reviews, citing a violation of Title 22 regulations related to refund policies.
Complaint Details
The complaint alleged that the authorized representative was not provided a refund for pre-admission fees. The allegation was substantiated after investigation, with the facility failing to provide a refund as required by Title 22 regulations.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Admissions Agreement Refund conditions not met; facility policy concerning refunds, including conditions for refunding advanced monthly fees, was not followed.
Type B
Report Facts
Capacity: 6Census: 5Deficiency Type: 1Plan of Correction Due Date: Jun 23, 2023Plan of Correction Due Date: Jun 30, 2023
Employees Mentioned
Name
Title
Context
Jeremiah Randle
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Arlene Feliciano
Administrator
Facility administrator who admitted the refund was not provided
An unannounced annual required and infection control visit was conducted to evaluate the facility's compliance with regulations.
Findings
The facility was found to be in good repair with no observed deficiencies. Infection control practices were in place, medications and files were properly stored and current, and safety equipment was operational.
An unannounced annual required visit was conducted with a primary focus on Infection Control measures using the new CARE Inspection Tool.
Findings
The facility was found to be sanitary, appropriately furnished, and compliant with infection control protocols. No deficiencies were cited during this inspection visit.