Providence Residential Care - Lakehurst

Type of visit: Required - 1 Year

At approximately 9:50 AM, Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conduct a required 1-year annual inspection and was greeted by staff member Mercedes Arabos who has Designation of Facility Responsibility (RP) who called licensee Annabelle Lewis-Barreto to advise of today's inspection. At 10:25 AM Kayla Barreto (RP) arrived to further assist with today's required inspection. Facility is a Residential Care Facility for the Elderly (RCFE) that is vendorized with the North Bay Regional Center. Facility currently cares for four (4) residents, all whom were away at day programming at the time of the inspection. Facility has a Dementia Care Plan, a Hospice waiver for four (4), with zero (0) Hospice residents currently in care, and is approved for all non-ambulatory residents. One bedridden resident can be served in room #1 only. At approximately 10:20 AM, LPA initiated a tour of the facility with RP and observed the following: Facility is a one (1) story home, was a comfortable temperature, and passageways were free from obstructions. Fire extinguishers were observed charged and last inspected 2/26. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Water temperature measured 118.7 degrees F, which is within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. LPA observed at least a two (2) day supply of perishable and seven (7) day supply of non-perishable food, as well as an emergency water supply. Food was found to be stored in a safe manner with open items covered and dated when taken out of their commercial bags. . Continued LIC809C... Continued from LIC809... There is a seating area in the backyard with outdoor space for activities. LPA observed two locked sheds in the backyard which LPA inspected and observed the contents to consist of tools and staff personal supplies. Licensee is advised to be mindful of tripping hazards in the backyard and continue to reduce the possibility of tripping incidents. Facility has an internet access device and internet available to clients in care. Facility conducts monthly disaster drills, and the most recent drill was conducted 06/26. LPA observed facility's infection control plan and emergency disaster plan which was last updated 02/26. LPA observed a supply of PPE, emergency supplies, a first aid kit, and flashlights. At approximately 11:00 AM LPA conducted review of four (4) resident records. All required documentation was present. At approximately 11:30 AM LPA conducted review of five (5) staff records. All required documentation was present. At approximately 12:00 PM LPA reviewed P & I monies and found their accounting to be accurate. At approximately 12:20 PM LPA conducted a spot check of medication and medication records. Medication is centrally stored and locked. Updated copies of the following documents were obtained during this visit: LIC500 - Personnel Report LIC 9020 - Resident Roster LIC610E - Emergency Disaster Plan **Licensee will send proof up updated Liability insurance in October when due. No deficiencies cited. Exit interview conducted with RP whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Aug 25, 2026

Type of visit: Required - 1 Year

At approximately 9:35 AM, Licensing Program Analyst (LPA) Elias Magdaleno arrived unannounced to conduct a required 1-year annual inspection and was greeted by staff. Administrator Annabelle Lewis-Barreto was contacted and arrived at approximately 10:15 AM. Facility is a Residential Care Facility for the Elderly (RCFE) with three (3) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for four (4), with zero (0) Hospice residents currently in care, and is approved for all non-ambulatory. One (1) bedridden resident in care. At approximately 10:20 AM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a one (1) story home, was a comfortable temperature, and passageways were free from obstructions. Fire extinguishers were observed charged and last inspected 2/25. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Water temperature measured 107.4 degrees F, which is within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. LPA observed at least a two (2) day supply of perishable and seven (7) day supply of non-perishable food, as well as an emergency water supply. Food was found to be stored in a safe manner with open items covered. Continued LIC809C... Continued from LIC809... There is a seating area in the backyard with outdoor space for activities. LPA observed two locked sheds in the backyard which LPA inspected and observed the contents to consist of tools and staff personal supplies. Facility has an internet access devise and internet available to clients in care. LPA gathered updated facility phone number during inspection. Facility does karaoke, has board games, and LPA observed staff ensuring residents were comfortable and stimulated during inspection. Facility conducts monthly disaster drills, and the most recent drill was conducted 6/25. LPA observed facility's infection control plan and emergency disaster plan which was last updated 4/25. LPA observed a supply of PPE, emergency supplies, a first aid kit, and flashlights. At approximately 10:50 AM LPA conducted review of three (3) resident records. All required documentation present. At approximately 11:10 AM LPA conducted review of two (2) staff records. All required documentation present. At approximately 11:20 PM LPA and Administrator conducted a spot check of medication and medication records. Medication is centrally stored and locked. Annabelle Barreto Administrator Certificate 7032445740 renewal submitted 6/28/2025. All fees are current as of this time. Updated copies of the following documents were gathered during this visit: LIC500 - Personnel Report LIC308 - Designation of Responsibility LIC400 - Affidavit Regarding Client Cash Resources LIC610E - Emergency Disaster Plan No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Aug 7, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required inspection visit for this facility and was greeted by Lead Staff, Arlene Ponce De Leon. Licensee, Annabelle Lewis-Barreto was contacted but was unable to attend the visit. The facility is a single story building licensed for 4 non-ambulatory residents. The facility currently provides care for 3 residents, all of which were present during inspection. There are currently no residents receiving hospice services but some of which have a diagnosis of dementia. LPA continued with a tour of the facility with Lead Staff (Designee), facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 2/26/2024. Both smoke detectors and carbon monoxide detectors throughout the facility were tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with additional food supplies in the garage. Facility also follows appropriate dietary protocol for resident in care. Toxins were located in the garage and laundry room both of which were found to be secured. LPA toured the facility backyard and found all bedroom screens in good repair and found one emergency exit located in the side yard to be clear and unobstructed. Two storage sheds located in the backyard were also found to be locked and secured. Residents were observed in their bedrooms watching television and preparing for following day’s outings. There was a supply of hygiene products and paper products available for residents. All resident bedrooms have lighting & appropriate furnishings. Water at faucets accessible to residents was measured within regulation. Medications located in dining area were found to be secured. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Store Medication Record. Upon medication count LPA found all administered medication to be in order. Continued onto LIC809-C Continued from LIC809 LPA conducted a file review for all 3 out of 3 residents and found all items including Physician's Reports and Needs & Service Plans to be updated. The facility conducts quarterly assessments for each resident or upon changes of condition. LPA and Lead Staff/Designee conducted a spot P&I count for residents and found all monies to be in order and not commingled. LPA was unable to complete today's inspection of Staff files and will return at another time.the state’s words, verbatim · CDSS document, Sep 24, 2024