Primrose 3

Type of visit: Required - 1 Year

On 10/07/25, at 8:15am., Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. Upon arrival, LPA met with Caregiver, Christopher Rogue de Guzman and disclosed the purpose of the visit. The administrator was called and stated they were out of town. LPA asked for the census, resident, and staff rosters. The facility tour started 8:55am Temperature of facility wall thermostat is observed and set to 76 degrees Fahrenheit. Medications-LPA observed medication stored in one (1) of the lower cabinets locked and secured in the kitchen area inaccessible to residents. Kitchen area was sufficiently stocked with seven (7) days of perishable and seven (7) days of non-perishable food. Sharps/Knives are stored and locked in one (1) of the cabinets in the kitchen on the right side of the sink. Toxins are kept secured and locked in one (1) of the cabinets under the kitchen sink inaccessible to residents. There is one (1) fire extinguisher located against the wall in the kitchen area on your left hand side fully charged and dated August 2025. There is a backyard which has outdoor furniture and grassy area for outdoor activities. There is no pool/and or bodies of water. LIC 809C-continued The garage is attached to the house and was observed to be locked and used to store toxins, extra storage. There is a washer and dryer located in this area. There is also one (1) refrigerator in the garage with extra food. Bedrooms/Bathrooms: There is five (5) bedrooms. One (1) bedroom is shared, three (3) bedrooms are single occupied. All five (5) bedrooms are properly furnished with proper lightning. The bathrooms have proper toiletry and grab bars. There is one (1) bathroom that is located by the entrance of the facility that is used by staff and residents. There are two (2) bedrooms that have private bathrooms. The bathroom temperature of the water are within regulations. It reads between 112.5-119 Degree Fahrenheit. Living and dining room furniture is accessible for six (6) residents and staff. There is a television, telephone line and enough seating for residents and staff. Furniture was observed to be in good condition and there is no fireplace. The smoke/carbon monoxide detectors are hardwired and interconnected and were tested. They were functional. Administrative: The Insurance plan is updated and expires on 07/2026, disaster plan, administrator certificate, Designation of facility responsibility, Admission Agreement, Personal Rights, resident rights signs are against the wall at the entrance of the facility, Infection Control and Disaster Plan, Ombudsman. Staff/Resident Files Reviewed: Six (6) resident files were reviewed and three (3) staff files were reviewed. Five (5) out of six (6) residents are missing functional capabilities form, five (5) out of six residents are missing resident appraisal form, One (1) resident is missing physician's report and tuberculosis, One (1) resident out of six (6) resident is missing pre-placement form, three (3) out of six (6) residents are missing needs and services plan. There are two (2) staff that are missing several forms such as Criminal Background/Fingerprinting, Personnel Record and education, training to provide medication to residents. An exit interview was conducted, several citation(s) were issued, appeals rights and a copy of this report was given to the caregiver that was present at the facility.the state’s words, verbatim · CDSS document, Oct 7, 2025

Type of visit: Required - 1 Year

On 09/30/24, at 11:45 am., Licensing Program Analysts (LPAs) Gina Saucedo and Angelica Segovia arrived at the facility to conduct an unannounced, annual visit. Upon arrival, LPA met with caregiver Chris de Guzman and disclosed the purpose of the visit. The designee administrator was called and arrived about twenty-five (25) minutes later. LPA asked for the census, resident, and staff rosters. The facility tour started 12:50 pm Temperature of facility wall thermostat is observed and set to 71 degrees Fahrenheit. Medications-LPA observed medication stored in cabinet locked and secured in the kitchen area inaccessible to residents in the kitchen area. Kitchen area was sufficiently stocked with seven (7) days of perishable and seven (7) days of non-perishable food. Sharps are stored and locked in one of the cabinets in the kitchen on the right side of the sink. Toxins are kept secured and locked in one of the cabinets under the kitchen sink inaccessible to residents. There is one (1) fire extinguisher located against the wall in the kitchen area fully charged and dated August 2025. There were two (2) complete first aid kits stored in overhead cabinet in the kitchen. There is a backyard which has outdoor furniture and grassy area for outdoor activities. There is no pool. LIC 809C-continued The garage is attached to the house and was observed to be locked and used to store toxins, washer, and dryer. There is also one (1) refrigerator in the garage with extra food. Bedrooms: There is five (5) resident bedrooms. There are two (2) bedrooms that have their private bathroom and are single occupied. One (1) bedroom that is shared and the other bedroom that is single, occupied. All five (5) bedrooms are properly furnished with proper lightning. The bathrooms have proper toiletry and grab bars. There is one bathroom that is located by the entrance of the facility that is used by staff and residents. The bathroom temperature of the water are within regulations. It reads between 114.4-118 Fahrenheit. Living and dining room furniture is accessible for five (5) residents. There is a television, telephone line and enough seating for five (5) residents. Furniture was observed to be in good condition and there is no fireplace. The smoke/carbon monoxide detectors are hardwired and interconnected and were tested. They were functional. Administrative: There is an annual fee due which is due as of 11/2023 for $495.00. The Insurance plan is updated and expires on 07/2025, disaster plan, administrator certificate, Designation of facility responsibility, Admission Agreement, Personal Rights, Staff LIS and resident rights signs are against the wall at the entrance of the facility, Infection Control and Disaster Plan, Ombudsman. An exit interview was conducted, two(2) citations were issued, appeals rights and a copy of this report was given to the designee administrator.the state’s words, verbatim · CDSS document, Sep 30, 2024

Type of visit: Required - 1 Year

On 01/03/24, at 08:35 a.m., Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. Upon arrival, LPA met with caregiver Janet Araba and disclosed the purpose of the visit. The administrator- Mubeen Naimuddin was called and arrived about fifteen (15) minutes later. LPA asked for the census, resident, and staff rosters. The facility tour started 09:20 a.m. Temperature of facility wall thermostat is observed and set to 75 degrees Fahrenheit. Medications-LPA observed medication stored in cabinet locked and secured in the kitchen area inaccessible to residents. Kitchen area was sufficiently stocked with seven (7) days of perishable and seven (7) days of non-perishable food. Sharps are stored and locked in one of the cabinets in the kitchen on the right side of the sink. Toxins are kept secured and locked in one of the cabinets under the kitchen sink inaccessible to residents. There is one fire extinguisher located against the wall in the kitchen area fully charged and dated February 2023. There were two (2) complete first aid kits stored in overhead cabinet in the kitchen. There is a backyard which has outdoor furniture and grassy area for outdoor activities. There is no pool. LIC 809C-continued The garage is attached to the house and was observed to be locked and used to store toxins, washer, and dryer. There is also one (1) refrigerator in the garage with extra food. Bedrooms: There is five (5) resident bedrooms. There are two bedrooms that have their private bathroom and are single occupied. One bedroom that is shared and the other bedroom that is single, occupied. All five (5) bedrooms are properly furnished with proper lightning. The bathrooms have proper toiletry and grab bars. There is one bathroom that is located by the entrance of the facility that is used by staff and residents. The bathroom temperature of the water are within regulations. It reads between 115.5-118.9 Fahrenheit. Living and dining room furniture is accessible for five (5) residents. There is a television, telephone line and enough seating for five (5) residents. Furniture was observed to be in good condition and there is no fireplace. The smoke/carbon monoxide detectors are hardwired and interconnected and were tested. They were functional. Administrative: There is an annual fee due which is due as of 11/2023 for $745.00. The Insurance plan is updated, disaster plan, administrator certificate, Designation of facility responsibility, Admission Agreement, Personal Rights, Staff LIS and resident rights signs are against the wall at the entrance of the facility. An exit interview was conducted, no citations were issued, and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Jan 3, 2024