Facility Evaluation Report

On 02/19/26, Licensing Program Analysts (LPAs) Aziz Faizi and Janette Romero made an unannounced visit to the facility to conduct a required annual inspection. LPAs were greeted and granted entry by Medication Technician (MT) Sandra Arena who was informed of the purpose of the visit. Administrator Renee Richardson was also notified of the purpose of LPAs visit. The facility has a fire clearance to serve 15 non-ambulatory elderly residents and has an approved hospice waiver for three (3). LPAs were informed two (2) residents are currently receiving hospice services at the facility.

LPAs toured the facility with MT Arena and observed the facility is made up a one-story building with eight (8) resident bedrooms, two (2) showers, a kitchen/dining room, staff office, medication room, and laundry room. No bodies of water were observed on the premises and indoor and outdoor pathways were free of obstruction. Outdoor shaded seating is available for the residents in care. Resident rooms had the required bedding, furniture, and lighting. Resident showers had grab bars and non-skid mats. LPA measured the hot water temperature in one of the bathrooms which measured at 109.2°F. Food for the residents is prepared in a different building within the premises. LPAs toured the kitchen and observed the facility met requirements for a two-day supply of perishable foods and a seven-day supply of non-perishable foods. All food was stored in a safe and healthy manner. Cleaning solutions and disinfectants are secured in a locked cabinet inside the laundry room. LPAs reviewed a fire code inspection letter addressed to the facility from the San Marcos Fire Department dated 06/26/2025 noting the fire alarms, suppression, exhaust, riser, extinguisher and elevator doors were inspected and deemed fire safe. LPAs observed three (3) charged fire extinguishers mounted throughout facility that were last serviced on 09/21/2025.

A record review conducted revealed Administrator Richardson's administrator certificate expires on 08/25/2026. Per a calendar reviewed, various activities are available for the residents. Staff and resident files reviewed contained all the Departmental required records. Medications are secured in a locked medication room. LPA reviewed medications for two (2) residents along with their Medication Administration Records, and no discrepancies were discovered. LPAs reviewed the facility’s emergency and disaster plan, including documentation noting their last fire/earthquake drill conducted on 12/29/2025. LPAs were also informed there are no known firearms are currently stored on the premises. During today's visit, no issues or concerns were observed and no deficiencies were cited. An exit interview was conducted, during which this report was reviewed and provided to MT Arena.