Compassionate Care Residence-Hendrix

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit. Upon arrival, LPA Mosley was greeted by staff who called the Administrator to inform them of the visit. The Administrator / Licensee Representative, David Flood arrived shortly after and the reason for the visit was explained. Entrance interview. The LPA and staff / Administrator 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. The facility is a single-story home located in a residential neighborhood. COMMON AREAS: This includes the family room, living room, and dining room. 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 12:27 p.m., hardwire combination of smoke / carbon monoxide detectors and fire doors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 2/17/2026. The emergency exiting plans/sketch are posted. The emergency telephone numbers are posted in the common hallway. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 2/13/2026 and 2/14/2026 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. Auditory alarms at the entrances and exits were observed and functional at the time of the visit. LPA observed surveillance cameras installed in the common areas of the facility. The Administrator presented the live monitoring screen to the LPA, confirming that all cameras were functioning properly and that none of them were equipped with audio capability. Report Continued on LIC 809-C PAGE 2... (PAGE 2) Report Continued from LIC 809-C... INTERVIEWS: Throughout the visit two (2) staff and two (2) resident interviews were conducted. Staff interviews 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 eight (8) total bedrooms in the facility; six (6) bedrooms are designated as private, single occupancy, resident rooms, one (1) is designated as a staff room, and one (1) is designated as a staff break room. The staff rooms are kept locked at all times and observed to be occupied by staff. Six (6) out of six (6) resident rooms have exits to the exterior. All passageways were observed to be clear of obstructions. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. RESTROOMS: There are four (4) total restrooms. One (1) is designated as a shared / common resident restroom, One (1) is designated as a private resident restroom, One (1) is designated as guest restroom, and one (1) is designated as a staff restroom. Resident restrooms were observed to be equipped with a slip resistant surface / mat. 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 measured within the required range. KITCHEN: The LPA inspected the kitchen/food service area. 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 111.9 degrees Fahrenheit, within the range. Cleaning supplies and other chemicals are kept locked in the attached garage adjacent from the kitchen. GARAGE: LPA observed the facility garage, which was locked and contained emergency food and water, emergency supplies, an extra freezer that was checked for proper labels and expiration dates, personal protection equipment (PPE) , incontinent supplies, a washer and dryer. Report Continued on LIC 809-C PAGE 3... (PAGE 3) Report Continued from LIC 809-C PAGE 2... RECORDS: Resident Records were reviewed beginning at 11:26 a.m. six (6) 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, Home Health records, Hospice records, PRN authorization letters, and current needs and services plan. All records were in order. Personnel Records 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 the LPA reviewed the facility’s infection control practices and the facilities emergency disaster plan. Both documents were observed to be complete and updated annually as required. The facilities policies and procedures, as they pertain to infection control and emergency planning meet the regulatory standard. MEDICATIONS: Medication review began at approximately 12:35 p.m. Medications are centrally stored and locked in a cabinet located in the hallway adjacent to the living room. Medications for three (3) residents were reviewed. Medications are labeled and checked for expiration dates. All medications including PRNs were properly documented on the centrally stored medications and destruction record, stored, locked and inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed. No errors observed during review. LPA observed the first aid supplies to be complete, including sterile first aid dressings, bandages, tweezer, a thermometer and a current version of a first aid manual. DOCUMENTS: Documents obtained during the visit include: LIC 500 facility roster and LIC 9020A Resident roster and copy of the Limited Liability insurance. At the time if the visit the LPA reviewed the facilities contact information on file including phone numbers, email and annual fees. Administrator made a change to the mobile number on file and confirmed that all information is accurate. No citations issued. Exit interview conducted. Copy of report reviewed and provided.the state’s words, verbatim · CDSS document, Mar 16, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Kelly Dulek and Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 11:57AM. The LPAs were greeted by staff and informed them of the reason for the visit. Administrator Kathie Flood and co-Administrator David Flood arrived shortly thereafter. Beginning at 01:06PM, the LPAs and Administrators 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. The following was observed: BEDROOMS/RESTROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are six (6) designated resident rooms, 1 (one) staff room and 1 (one) staff break room. There are 3 (three) total bathrooms in the facility; 1 (one) is designated as a shared resident restroom, 1 (one) is a private bathroom and 1 (one) is designated as a staff restroom. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap and paper towels. Hot water was tested in the common restroom and measured within the required range. COMMON AREAS: At the time of the visit, living room, family room, and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which was observed to be screened and inaccessible. The facility maintained a comfortable temperature throughout the visit. Hardwired combination smoke and carbon monoxide detectors as well as fire doors were tested at 01:37PM and were operational at the time of the visit. The fire extinguisher was fully charged and purchased on 02/25/2025. The LPAs observed required postings on the dining room wall. KITCHEN: The LPAs observed the facility kitchen. Knives are stored inaccessible. Cleaning supplies are stored inaccessible in the attached garage. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Continued on LIC 809-C OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for resident use. There are 2 (two) side gates for emergency exit use and are single latched. No bodies of water noted and exits are free of obstructions. The attached garage is where the washer and dryer are held. There was a linen closet with extra towels and linens. Cleaning supplies and disinfectants are kept in locked in the garage. The LPAs observed additional perishable and non-perishable food supply, emergency water, additional Personal Protection Equipment (PPE) and supplies. RECORDS: Records review began at 12:20PM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medications review began at 02:16PM; medications are centrally stored and kept locked in a cabinet in the office. Medications were observed for 2 (two) residents. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPAs reviewed the facility's infection control plan and emergency disaster plan. The facility's procedures as it pertains to infection control are adequate. Both documents were observed to be complete and updated annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 01/24/2025. INTERVIEWS: During today's visit, LPAs interviewed 1 (one) staff and 2 (two) residents. No concerns were noted. The LPAs obtained the following documents: - LIC500 Personnel Report - Liability Insurance No deficiencies cited. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Feb 28, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 11:30 a.m. LPA was greeted by House Manager Marilona Manalang and informed them of the reason for the visit. Administrator David Flood shortly arrived. At 11:50 a.m. the LPA conducted a tour of the physical plant with Administrator David. The following was noted: Facility is a single-story residence that consists of six (6) resident bedrooms, two (2) staff rooms and three (3) bathrooms. The LPA observed (1) fully charged fire extinguisher purchased on October 18, 2023. All smoke alarms and carbon monoxide detectors were tested and functioned properly during time of visit. LPA observed all required postings in the dining area of the home. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; Sharp objects are stored in a locked drawer. Bedrooms: The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Bathrooms: LPA observed all bathrooms clean, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. At 11:55 a.m. water temperature in resident’s bedroom restroom was measured at 113.4 degrees Fahrenheit. At 12:00 p.m. water temperature in the shared resident’s bathroom was measured at 113.4 degrees Fahrenheit. REPORT WILL CONTINUE ON LIC809-C. Common Areas: These included the living rooms and dining areas. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a fireplace in the first living room, which is covered with a screen. The facility maintained a comfortable temperature of 72 degrees. Garage: The garage is where the washer and dryer are held, including additional non-perishable emergency food and water. Cleaning supplies and disinfectants are kept in locked cabinets in the garage. Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises. File review: At 12:25 p.m. a review of facility files was initiated, and the following was observed. The LPA reviewed five (5) of five (5) resident files. All documents reviewed appeared complete and current. The LPA reviewed five (5) out of eight (8) staff files. All documents reviewed appeared complete and current. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 02/02/2024). The LPA obtained Client Roster, Staff Roster, and copy of the insurance liability. Interviews: The LPA conducted two (2) staff and two (2) resident Interviews. No immediate concerns voiced during the visit. Medication audit: Medications review began at 02:53 p.m.; medications are centrally stored and locked in a cabinet in an office; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. Exit interview conducted and copy of the report and appeal rights provided to Administrator David Flood.the state’s words, verbatim · CDSS document, Mar 18, 2024

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.