Kelly's Sunset Villa

Type of visit: Required - 1 Year

On 4/22/26, Licensing Program Analyst (LPA) Kyle Wellington arrived unannounced to conduct an annual inspection. LPA was greeted and let into the facility by Caregiver, Cristina Agoscruz, who was informed of the purpose of the visit. Administrator (Admin), Garrett Welker, arrived shortly thereafter to the facility to meet with LPA. LPA observed two (2) staff and four (4) residents present at the facility. The census at the facility is five (5) residents with one (1) resident in the hospital. Two (2) residents are receiving hospice care. LPA received a staff and resident roster from the Caregiver. LPA toured the inside and outside of the facility with the Caregiver. LPA conducted an observation and record reviews for the inspection. Facility Overview: The facility is a one story house with six (6) resident bedrooms, one (1) staff room, two (2) resident bathrooms, one (1) staff bathroom, kitchen, dining room, family room, laundry room and attached garage. There were no pools, bodies of water or firearms at the facility. Facility has a fire clearance to serve six (6) non-ambulatory elderly residents of which one (1) may be bedridden. Facility has an approved hospice waiver for six (6) residents. Infection Control: LPA observed hand soap dispensers and hand sanitizers throughout the facility. Cleaning equipment and cleaning supplies were kept locked in the garage and available for regular facility maintenance. LPA reviewed the facility’s infection control plan which met the department’s requirements. Physical Plant: LPA observed the inside and outside of the facility to be clean, safe and well kept. The floors, windows and doors were clean and well maintained. The family room and dining room furniture was in good repair. The halls had night lights and no obstructions. The residents’ bedrooms were neat, organized and had the required bedding, furniture and lighting. Bathrooms were clean, tidy and contained soap, paper towels, grab bars and non-slip tile in the showers. The hot water temperature in the bathroom was measured at 108.2 F. Clean linens and towels were readily available in a cabinet in the hall. Laundry equipment appeared to be in good working condition. Laundry supplies were kept in a cabinet in the locked laundry room. Incontinent supplies and cleaning supplies were stored separate from the emergency food and water in the locked garage. The one (1) fire extinguisher was charged and available for use. LPA and Admin tested one (1) of the smoke and carbon monoxide detectors and found it to be operational and hard wired. Facility had a pull system fire alarm in the hall. The backyard was clean, free of hazards and contained outdoor furniture and shaded areas for the residents. Kitchen/Food Service: LPA observed the kitchen to be clean, organized, and well maintained. The kitchen had the ability to prepare and store food in a safe and clean environment. Kitchen appliances appeared to be in good working condition. All sharp and dangerous objects were kept in a locked drawer in the kitchen inaccessible to residents. Cleaning supplies were kept in a locked cabinet under the sink inaccessible to residents. The refrigerator/freezer was clean, stocked and at the required temperatures. Food in the refrigerator/freezer and cabinets was properly stores and not expired. The facility has at least a two day supply of perishable foods and a seven day supply of non perishable foods. The hot water temperature in the kitchen was measured at 110.4 F. Care & Supervision: LPA observed the facility had sufficient staff present to supervise the residents. Administration: LPA observed that the facility's license, Long Term Care Ombudsman information, residents' personal rights information and complaint information was posted in the hall near the front door. Liability insurance was up to date. Admin holds a current Administrator Certificate and CPR Certification. Admin has a criminal record clearance. Record Review and Resident/Staff Files: LPA compared the staff present at the facility and on the staff roster to the Guardian staff roster for criminal record clearance. LPA reviewed the records of two (2) staff files and three (3) residents’ files. The files contained all the required documentation and paperwork. The staff and residents’ files were kept in a locked closet in the kitchen inaccessible to unauthorized individuals. Health Related Services/Incidental Medical Services: LPA observed all residents’ medications were kept in a locked in a cabinet in the kitchen inaccessible to residents. LPA reviewed two (2) residents' medication to the facility’s medication log to make sure all medication was accounted for and dispensed correctly. First Aid kit contained all the required items and was kept in a locked closet in the kitchen inaccessible to residents. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan. The plan was current and up to date. Safety and fire drills have been conducted. All facility exits were clear of obstructions. No deficiencies were cited during this visit. Exit interview was conducted with the Administrator and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Apr 22, 2026

Type of visit: Required - 1 Year

On 4/14/2025, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to conduct a required annual inspection. LPA was greeted and granted entry by Caregiver, Christina Agoscruz who was informed of the purpose of the visit. One of the facility administrators, Garrett Welker arrived to the facility to meet with LPA. The facility has a fire clearance to serve six (6) non-ambulatory elderly residents of which one (1) may be bedridden. The facility also has an approved hospice waiver for six (6) and LPA was informed two (2) residents are currently receiving hospice services at the facility. During today's visit, there was three (3) staff and six (6) residents present. LPA toured the facility with Agoscruz and observed the facility is made up of a one-story home with six (6) resident bedrooms, three (3) restrooms, a kitchen, dining area, living room, laundry room, and attached garage. Resident bedrooms had the required bedding, furniture, and lighting. Bathrooms had grab bars and non-skid mats in the showers. No bodies of water were observed on the premises. Indoor and outdoor pathways were free of obstruction. The facility had more than a two-day supply of perishable foods and seven-day supply of non-perishable foods. Medications are secured in a locked kitchen closet. LPA toured the garage and observed an additional incontinent supplies, cleaning solutions and disinfectants stored separately from the food and water. Agoscruz tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed a charged fire extinguisher mounted near the kitchen last serviced on 11/1/2024. The facility's certificate of liability insurance expires on 5/1/2025. Staff present have a criminal record clearance and are associated with the facility. Resident files reviewed had updated physician's reports and signed admission agreements. LPA reviewed the facility's Fire & Emergency Disaster Training noting the facility's last fire drill was conducted on 4/1/2025. Long Term Care Ombudsman's contact information, residents' personal rights, complaint procedures and facility sketch are visibly posted near the front entrance. During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Welker.the state’s words, verbatim · CDSS document, Apr 14, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jacqueline Shaw Ross made an unannounced visit to the facility to conduct an annual licensing inspection. LPA was met by Cristina Agoscruz, Caregiver. Administrator Garrett Welker arrived shortly. A tour of the facility was conducted inside and out. LPA conducted a general overall inspection, which included but was not limited to the following: Facility physical plant, food service, medication management, record review and facility administration. The facility is a one story six (6) bedroom, three (3) bathroom home. During today's inspection, LPA observed the following: Indoor and outdoor passageways were observed to be free from obstruction. There are no pools or bodies of water. There are no firearms or other dangerous weapons in the facility. Poisons and cleaning agents were observed to be secured and inaccessible to residents in care. Facility fire clearance is maintained in conformity with State Fire Marshal regulations. LPA toured every room in the facility. Rooms designated as resident rooms had the required furnishings and sufficient lighting available. Licensee provided each resident with clean linen, in good repair, and sufficient hygiene products for personal use. The hot water temperature measured at 115 degrees F. The facility had functioning carbon monoxide detectors, multiple smoke detectors, and one operable fire extinguisher. The facility was stocked with a two-day supply of perishable food items and a seven-day supply of nonperishable food items. Staff records were reviewed and contained CPR/First Aid training, Health Screening Reports, and annual training. Resident records were reviewed and had a current Physician's Report, Resident Appraisal, Identification and Emergency Information, Admission Agreement, and Centrally Stored Medication and Destruction Records. LPA observed medications are stored and dispensed according to physician's orders No deficiencies were observed during today's inspection. An exit interview was conducted and copy of this report was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 24, 2024