Sarah's Care Home

Type of visit: Required - 1 Year

On 01/31/2026 at 10:00 am Licensing Program Analyst (LPA) Lorena Casillas met with Administrator Stephen Racine for an unannounced one (1) year Required visit for this facility. LPA was greeted and granted access by Administrator, LPA informed the Administrator of the purpose of the visit, and an entrance interview was conducted. Infection Control and Emergency Preparedness Plans: LPA reviewed the facility mitigation plan (approved on 04/15/21) to make sure the licensee was following current infection control recommendations. LPA also reviewed facility emergency preparedness plan and quarterly emergency drills. A tour of the physical plant was conducted with the Administrator at 11:00 am. The facility has six (6) bedrooms and two (2) bathrooms currently occupying three (3) residents. One (1) bedroom is designated for staff use only. The facility is Fire Cleared for six (6) ambulatory of which five (5) can be non-ambulatory, and a hospice waiver for four (4). Currently the facility has no residents in hospice. All three (3) residents were present and in their rooms. Kitchen: At approximately 11:00 am LPA conducted a tour of the kitchen and observed there to be sufficient stock of two-day perishable and seven-day non-perishable foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed all knives and sharp objects locked and inaccessible to residents in care. There is a pantry located in the hallway that has a fridge for additional food storage. Continued on LIC809-C Common Areas: LPA observed the living room to be neat and clean along with the dining room. The facility maintains a temperature of 71°F. The dual smoke detectors and carbon monoxide detectors were tested and observed to be operational. There are two (2) fire extinguishers, one (1) is in the kitchen and one (1) is in the hallway. The Fire extinguishers were observed to be full and last purchased on 10/02/25. The files and medication were observed to be locked in a separate room near the entrance. Resident Rooms: LPA observed rooms to have the appropriate bedding. There is a nightstand, a chair and sufficient lighting for each client. LPA observed the staff room to be locked and inaccessible to residents. Bathrooms: LPA observed all bathrooms to have non-skid mats, grab bars, and the appropriate wash your hands signs posted. Hot water was tested and measured within regulation at 108˚ F. Laundry: Laundry room is adjacent to the staff room and has a functioning washer and dryer. Cleaning detergents and supplies were observed to be locked and inaccessible to residents. Surrounding Grounds: At approximately 12:00 pm LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. No bodies of water on the premises. Garage: LPA observed a locked attached garage used for extra storage. Administrative: Annual fee is current. Administrator Certificate, LIC 500, Liability Insurance, and Client roster were collected. Resident and Staff Files: At approximately 1:00 pm LPA conducted a file review of resident and staff records. Medications: At approximately 3:00 pm LPA and Administrator reviewed medication and medication records. Staff and Resident Interviews: Throughout the visit LPA interviewed residents and staff. No citations issued. Exit interview conducted. Copy report given to the Administrator.the state’s words, verbatim · CDSS document, Jan 31, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lorena Casillas met with back up administrator Stephen Racine for an unannounced one (1) year Required visit for this facility. LPA arrived at 09:30 am and was greeted by Administrator. All four (4) residents were present and in their rooms. LPA informed the Administrator of the purpose of the visit. Infection control: LPA previously reviewed the facility mitigation plan (approved on 04/15/21) to make sure the licensee was following current infection control recommendations. A tour of the physical plant was conducted with the Administrator at 9:50 am. The facility has six (6) bedrooms and two (2) bathrooms currently occupying four (4) residents. One (1) bedroom is designated for staff use only. The facility is Fire Cleared for six (6) ambulatory of which five (5) can be non-ambulatory, and a hospice waiver for four (4). Currently the facility three (3) residents on hospice. Food Inspection: LPA conducted a tour of the kitchen around 10:00 am and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas care clean and inaccessible to pests. LPA observed all knives and sharp objects being locked and inaccessible to residents in care. The files and medication were observed to be locked in a cabinet and inaccessible to residents in care in a separate room near the entrance. There is a pantry located in the hallway that has a fridge for additional food storage. Resident Rooms: LPA observed rooms to have the appropriate bedding. There is a nightstand, a chair and sufficient lighting for each client. LPA observed the staff room to have a locked. There is an office with an additional freezer. Bathrooms: LPA observed all bathrooms to have non-skid mats, grab bars, and the appropriated wash your hands signs posted. Hot water was tested and measured within regulation at 105 degrees F. Living and dining: LPA observed the living room to be neat and clean along with the dining room. The facility maintains a temperature of 70°F. The dual smoke detectors and carbon monoxide detectors were tested and observed to be operational. There are two (2) fire extinguishers, one (1) is in the kitchen and one (1) is in the hallway. The Fire extinguishers were observed to be full and last purchased on 9/18/24. Laundry: LPA observed the laundry room to not have any chemicals or hazardous items. Detergent is kept in the locked office. Physical environment: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. No bodies of water on the premises. Garage: LPA observed a locked attached garage used for extra storage. Administrative: Annual fee is current. Administrator Certificate, LIC 500, Liability Insurance, and Client roster were collected. Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms. Staff Files: LPA conducted a file review of staff records to ensure compliance of licensing forms. Medications: LPA and Administrator reviewed medication and medication records for proper documentation. Staff Interviews: At 01:00 pm LPA interviewed staff. Client Interviews: At 01:30 pm LPA interviewed clients. An exit interview was conducted, and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Dec 2, 2024

Allegation investigated: Staff do not meet resident's bathing needs. Staff did not seek medical attention for resident in care. Staff do not ensure facility is free of lice resulting in residents being infected. Staff do not ensure resident is being scheduled for therapy appointments. Illegal eviction

On 05/29/24 at 10:00 am Licensing Program Analyst (LPA), Lorena Casillas conducted an unannounced complaint visit to investigate the above stated allegation. LPA met with Administrator Steven Racine and explained the reason for the visit. At 10:10 AM LPA Casillas conducted a physical plant tour. During the investigation, interviews and record reviews were conducted. LPA requested copies of resident roster and LIC 500. LPA requested copies of pertinent information relevant to the investigation including but not limited to appraisals, police reports, police agency information and any information pertaining to residents and care. During LPA’s visit Bristol Hospice Registered Nurse arrived and LPA was able to interview them and gather further information. Continued on LIC9099-C Unsubstantiated Allegation #1 Staff does not meet resident's bathing needs. It is alleged that staff do not meet residents’ bathing needs. Regarding this allegation it was reported that Resident #1 (R1) was only receiving bed baths every 8 days as opposed to regular baths, leaving R1’s legs and feet feeling unclean. LPA interviewed Administrator and staff and it was discovered that R1 cannot be left unattended in the shower and has refused help, therefore R1 has been given bed baths to keep them clean. Upon R1’s record review it was discovered that R1 is in Hospice and Hospice is in charge of R1’s bathing needs. LPA read R1’s medical assessment and Hospice documentation it was revealed that R1 cannot bathe on their own. The documentation revealed that R1 has refused to be bathed multiple times. Furthermore, interviews with residents revealed that they are cleaned often and helped with any and all grooming if they so chose it. Therefore, based on interviews, record reviews and observations this allegation is deemed Unsubstantiated. Allegation #2 Staff did not seek medical attention for resident in care. It is alleged that staff did not seek medical attention for resident in care. Regarding this allegation it was reported that Resident #1 (R1) was not helped with seeking medical attention for their concerns. LPA interviewed Administrator, staff and R1 and it was revealed that doctor appointments are done by Bristol Hospice. Furthermore, it was revealed that medical assistance such as calling 911 during an emergency has been used for all residents when it is needed. Resident interviews also revealed that they also have access to call 911 if they need to. R1 revealed during interview that their complaint is for Hospice care not the facility, they also admitted to getting the facility confused with Bristol Hospice. Therefore, based on LPA observations, record reviews and interviews this allegation is deemed Unsubstantiated. Allegation #3 Staff do not ensure facility is free of lice resulting in residents being infected. It is alleged that staff do not ensure facility is free of lice resulting in residents being infected. Regarding this allegation it was reported that facility staff have allowed residents to continue to have lice resulting in an infestation. LPA interviewed Administrator and staff and it was revealed that residents are free of lice or any other pests. Staff #1 (S1) states that they make sure that there are no lice on R1 or any of the residents since S1 is in close contact while providing care to residents. During LPA’s tour of the facility, it was observed that facility is clean and free of pests. During interview with four (4) of five (5) residents, LPA was informed that they do not have lice on their person. Therefore, based on interviews, record reviews and observations this allegation is deemed Unsubstantiated. Continue on LIC9099-C Allegation #4 Staff do not ensure resident is being scheduled for therapy appointments. It is alleged that Staff do not ensure resident is being scheduled for therapy appointments. Regarding this allegation, it was reported that Resident #1 (R1) has not been scheduled for their physical therapy appointments. During the investigation LPA reviewed R1’s medical documentation and it was revealed that Bristol Hospice did an initial evaluation for R1 for Physical Therapy however R1 did not cooperate, and a complete evaluation was not able to me made. Furthermore, LPA interviewed Administrator, staff and Hospice Nurse and discovered that there was only an evaluation ordered but there is no physical therapy order documented or ordered from any provider. Therefore, based on interviews, observations, and record reviews this allegation is deemed Unsubstantiated. Allegation #5 Illegal eviction It is alleged that an Illegal Eviction has taken place. Regarding this allegation, it is reported that Resident #1 (R1) is being illegally evicted. LPA confirmed with Community Care Licensing (CCL) Regional Office (RO) that there was a denial for a 3-day eviction, however there is no evidence of a 30-day eviction. LPA interviewed Administrator and it was revealed that there has been no eviction notice initiated after the denial of the 3-day eviction notice. The facility Administrator stated that they have found a facility with the ability to care for R1, as this facility is not able to care for R1 appropriately based on their changing needs. However, R1 refuses to leave to a new facility. Administrator has stated that they will continue to provide care as best they can to all residents in care. Furthermore, interview with R1 revealed that they have not received any documentation regarding an eviction. R1 admits that they have refused the new facility. Therefore, based on interviews, observations, and record reviews this allegation is deemed Unsubstantiated. No citations Issued. A copy of this report was given to Administrator.the state’s words, verbatim · CDSS document, May 29, 2024 · control 31-AS-20240522145500

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lorena Casillas met with back up administrator Stephen Racine for an unannounced one (1) year Required visit for this facility. LPA arrived at 09:30 am and was greeted by Administrator. All four (4) residents were present and in their rooms. LPA informed the Administrator of the purpose of the visit. Infection control: LPA previously reviewed the facility mitigation plan (approved on 04/15/21) to make sure the licensee was following current infection control recommendations. A tour of the physical plant was conducted with the Administrator at 9:50 am. The facility has six (6) bedrooms and two (2) bathrooms currently occupying four (4) residents. One (1) bedroom is designated for staff use only. The facility is Fire Cleared for six (6) ambulatory of which five (5) can be non-ambulatory, and a hospice waiver for four (4). Currently the facility two (2) residents on hospice. Food Inspection: LPA conducted a tour of the kitchen around 10:00 am and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed all knives and sharp objects being locked and inaccessible to residents in care. The files and medication cabinet was observed to be locked and inaccessible to residents in care in a separate locked room near the entrance. There is a pantry located in the hallway that has a fridge for additional food storage. Continued on LIC809-C Resident Rooms: LPA observed rooms to have the appropriate bedding. There is a night stand, a chair and sufficient lighting for each client. Bathrooms: LPA observed all bathrooms to have non-skid mats, grab bars, and the appropriated wash your hands signs posted. Hot water was tested and measured within regulation at 111.8 degrees F. Living and dining: LPA observed the living room to be neat and clean along with the dining room. The facility maintains a temperature of 71°F. The dual smoke detectors and carbon monoxide detectors were tested and observed to be operational. There are two (2) fire extinguishers, one (1) is in the kitchen and one (1) is in the hallway. The Fire extinguishers were observed to be full and last purchased on 9/15/23. LPA observed the laundry room to not have any chemicals or hazardous items. Physical environment: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. No bodies of water on the premises. Administrative: Annual fee is current. Administrator Certificate, LIC 500, Liability Insurance, and Client roster were collected. Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms. Staff Files: LPA conducted a file review of staff records to ensure compliance of licensing forms. Medications: LPA and Administrator reviewed medication and medication records for proper documentation. Staff Interviews: At 12:38 pm LPA interviewed staff. Client Interviews: At 12:52 pm LPA interviewed clients. An exit interview was conducted, and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Feb 12, 2024