Homelife Senior Living 5

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 9:30 a.m. Upon arrival, LPA Mosley was greeted by staff who called the Administrator who arrived shortly after. LPA met with Administrator,Designee Dvora "Debbie" Leventer and the reason for the visit was explained. Entrance interview. The LPA and 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. COMMON AREAS: This includes the 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 12:02 p.m., hardwire combination of smoke, carbon monoxide detectors, and fire door were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 11/07/2024. 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 fireplace in the living room was adequately screened. The last emergency disaster drill took place on 10/10/2025 and are conducted quarterly. Activities were observed in the common areas. 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 however all are inactive and will remain inactive. INTERVIEWS: Starting at 9:30 a.m. and 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 interviews revealed that no concerns were noted or voiced at the time of the visit. Report Continued on LIC 809-C PAGE 2... (PAGE 2) Report Continued from LIC 809-C... KITCHEN: The LPA inspected the kitchen/food service area at 9:59 a.m. 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 107.4 degrees Fahrenheit at 10:01 a.m. Cleaning supplies and other chemicals are kept in the locked laundry room inaccessible to residents in care. BEDROOMS: There are seven (7) total bedrooms in the facility; six (6) bedrooms are designated as private, single occupancy, resident rooms and one (1) staff room. The staff room is kept locked at all times and observed to be occupied by staff. One (1) out of six (6) resident rooms has an exit 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 seven (7) total restrooms. One (1) is designated as a staff / guest restroom, six (6) are designated as a private resident restrooms. 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 ranged between 107.8-112.5 degrees Fahrenheit, all within the required range. LPA observed storage space closets in hallway containing extra clean linens and towels for resident use. LAUNDRY ROOM: LPA observed the locked laundry room adjacent to the main hallway. Laundry room has a washer and dryer and locked cleaning supplies. EXTERIOR: The exterior passageways were clean and clear of any obstructions. There is a covered patio area with tables and chairs for resident use located outside the front entrance. There are three (3) additional licensed facilities on the property. All four (4) facilities share a common recreation area with additional covered patio with furniture, and a putting green for resident use. There were no bodies of water noted at the time of the visit. The driveway gate is kept unlocked. GARAGE: The garage was observed to be locked and contain storage, a refrigerator and freezer, both containing extra food. Both were checked for proper labels and expiration dates. 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 10:44 a.m. five (5) 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, and current needs and services plan. All records were in order. Personnel Records were reviewed beginning at 11:26 a.m. Five (5) 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 12:15 p.m. Medications are centrally stored and locked in a closet in the main hallway adjacent to the entrance to the home. Medications for three (3) residents were reviewed. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self administered as prescribed and documented on the centrally stored medication and destruction records. No errors observed during review. LPA observed the first aid supplies to be complete, including a thermometer , extra flashlights / lighting and a current version of a first aid manual. DOCUMENTS: Documents obtained during the visit include: LIC 500 Facility roster, LIC 9020A Resident roster and copy of the current Limited Liability insurance. During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. Exit interview conducted. Copy of report reviewed and provided.the state’s words, verbatim · CDSS document, Oct 22, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced at 10:20AM with the purpose of conducting a required annual visit. The LPA initially met with facility staff. Administrator Dvora "Debbie" Leventer was contacted via telephone and arrived shortly thereafter. Entrance interview conducted. This facility has no residents in care at this time, and have not had residents in care since the date of licensure. Therefore, the physical plant areas were observed, however no files were observed and no interviews were conducted. Beginning at 11:05AM, the LPA, along with 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 following was observed: Fire extinguisher was observed to be fully charged and last serviced 06/03/2024. BEDROOMS: There are (7) seven bedrooms in the facility; the facility has (6) six private bedrooms for resident use, and (1) one room that is used as a staff room. The staff room will be kept locked. BATHROOMS: There are (7) seven full bathrooms. There are (6) six private bathrooms for resident use, the full bathroom at the entrance of the home next to Room A (Staff room) is designated for staff and guests. The showers are equipped with nonskid surfaces and available nonskid mats. Grab bars were observed in the bathrooms. LAUNDRY: The laundry area is in a locked laundry room located in the main hallway. Laundry detergent and cleaning supplies are stored inaccessible in the locked laundry room. GARAGE: The garage was observed to be locked and contain storage, a refrigerator and freezer. Report Continued on LIC 809-C COMMON AREA: The common areas were appropriately furnished and the lighting was adequate. There is a television and other entertainment equipment in the living room area. There is a functioning telephone on the premises. All required postings were observed on the entrance area wall. Emergency exiting plans/sketch are posted. Auditory alarms were observed on all exit doors. KITCHEN: Appliances in the kitchen were clean and appeared functional. The facility has an adequate supply of non-perishable food and emergency food and water supply. EXTERIOR: The exterior passageways were clean and clear of any obstructions. There is a covered patio area with tables and chairs for resident use. There are 3 (three) additional licensed facilities on the property. All 4 (four) facilities share a common recreation area with additional covered patio with furniture, a putting green, and bocce ball area for resident use. There are no bodies of water noted on the premises. There is no front yard gate and the driveway gate is kept unlocked. RESIDENT & STAFF RECORDS: Records were not reviewed as there are no residents in care at this time. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. The facility's policies as it pertains to infection control are adequate. The facility's emergency disaster plan was observed to be complete and updated annually, as required. MEDICATIONS: Medications were not observed, as there are no residents in care at this time. INTERVIEWS: No interviews were conducted, as there are no residents in care at this time. No citations issued. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Sep 20, 2024

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Elsie Campos arrived at the facility announced at 12:30 p.m. to conduct a pre-licensing inspection. This application is for Homelife Senior Living 5 (#565850372). The LPA met with Administrator Devora ‘Debbie’ Leventer. Rooms are cleared for all bedridden residents. The fire clearance was granted on 6/21/2023; in which bedridden residents are permitted in Bedrooms B-G. Component III was waived as the applicant has attended Component III in the past and is RCFE administrator certified. At 12:45 p.m., the LPA toured the physical plant areas inside and outside with the Administrator to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Kitchen knives are stored locked and inaccessible in a drawer at the kitchen island. The supply of nonperishable food is adequate. The supply of dishes is adequate. Appliances in the kitchen were clean and functional. There is an adequate supply of emergency food and water. The facility recently completed a full home repaint and replaced furniture and kitchen supplies. BEDROOMS: There are (7) seven bedrooms in the facility; the facility has (6) six private bedrooms for resident use, and (1) one room that is used as staff office and to store files. The staff room is kept locked. Rooms B-F have indirect access to the outside and Room G has direct access to the outside. Lighting in the rooms is adequate. (6) six out of (6) six private resident rooms were set up with beds, nightstands, lighting, chests of drawers, chairs and closet space. BATHROOMS: There are (7) seven full bathrooms. There are (6) six private bathrooms for resident use, the full bathroom at the entrance of the home next to Room A staff office is designated for staff and guests. The showers are equipped with nonskid surfaces and available nonskid mats. Grab bars were observed in the bathrooms. Hot water temperature in bathrooms measured between 108.6 – 118.9 degrees Fahrenheit. Continued on LIC 809-C. COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment in the living room area. The living room has a covered fireplace. The facility smoke alarm system is hardwired; the smoke detectors were operable at the time of the visit. There are two (2) fire extinguishers which were fully charged and last serviced 6/12/2023. There is a functioning telephone on the premises. Emergency exiting plans/sketch are posted. Emergency telephone numbers are posted in the entrance area wall. Other required postings are also posted on the entrance area wall. MEDICATIONS: Medications are kept in medication closet located in the main hallway and is kept locked with a self closing digital lock. The first aid supplies were complete, including a first aid manual. FILES: Resident and staff records are stored in the locked staff/office room and locked medication closet. LAUNDRY: The laundry area is in a locked laundry room located in the main hallway. Laundry detergent and cleaning supplies are stored inaccessible in the locked laundry room. EXTERIOR: The exterior passageways were clean and clear of any obstructions. There is a covered patio area with tables and chairs for resident use located outside the living room entrance. There is common recreational area with additional covered patio area with furniture a putting green and bocce ball area for resident use. There are no bodies of water noted on the premises. There is no front yard gate the driveway gate is kept open. The garage is attached to the property and is used for additional storage. There are 3 other structures on the property which will be licensed individually as part of the same ownership. INFECTION CONTROL: The facility has a central entry point for symptom screening and sanitation station for staff, residents, and visitors. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. Facility is in compliance with Title 22 Regulations at this time. This report will be sent to the Centralized Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. The applicant is aware that they are unable to operate under the new license number until they have been notified that the license has been approved by the CAB Analyst. Failure to comply could affect approval of the license. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Oct 3, 2023