St. Cecilia's Senior Home V

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vaid conducted an announced annual inspection. LPA was allowed entry by Marilyn Figueroa-DSP, informed Tiffany Vander Poorten, administrator/licensee who arrived shortly after and assisted with the inspection. The capacity is six (6). Facility has an approved Dementia Care Plan. Hospice waiver is approved for six (6). Currently five (5) residents are residing. The property is a single-family residence located in a neighborhood, consisting of four (4) bedrooms, two (2) full bathrooms, one (1) half bathroom, kitchen, dining room/living room with TV, laundry room, family room, administrator office, kitchen, and detached garage. Passageways, walkways and patios are free from obstructions. The entrance and side areas are free of hazards and debris. Garage is not accessible to residents. Fire clearance was granted for six (6) non-ambulatory and zero (0) bedridden. Fire clearance and Dementia care plan are in place. Auditory devices are installed at all exits and operable. Bedroom#1 and #2 are approved for one (1) non- ambulatory in each room. Bedrooms #3 and #4 are approved for two (2) non- ambulatory in each room. Garage is not approved for residents or staff residence. Bedrooms have nightstand, adequate lighting, adequate closet and drawer space. Bedrooms are spacious and allow for easy passage between and comfortable for usage. Toilet, wash basin, bathtub/shower in bathrooms are operable. Bedrooms are accommodated for residents. Grab bars are maintained for each toilet, bathtub and shower. Adequate supply of linen, wash clothes and towels are observed. Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet in the kitchen and inaccessible to residents. Food supply consist of two days of perishable and two weeks of non-perishable was observed. Continued on 809C..... Medication cabinet is installed with a lock and inaccessible to residents. First aid kit has required items. First Aid manual from American red cross was available for staff use and inaccessible to residents. Dual Smoke /carbon monoxide detectors are tested and operable. They are located in hallways and each bedroom. Poisons, toxins, and cleaning supplies are locked and inaccessible to residents. They are stored separately from food source. Outdoor activity area is furnished with chairs and table and in compliance. Locked cabinets for records of staff and residents are installed and available. Residents file are observed Water Tested at 117.6 degrees Fahrenheit. Menus are available for review. Free landline telephone is available for residents’ use and operable. Fire extinguishers are available in the facility. They are fully charged. Exit conference was conducted, copy of this report was provided to Licensee Tiffany Vander Poorten. Technical Violation regarding proper recording of medications was provided and discussed. Licensee will update the Medication administered record, provide proof for five residents Medication Administered Record.the state’s words, verbatim · CDSS document, Oct 23, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Tao conducted an announced pre-licensing inspection. Applicant is applying for Residential Care for Elderly to serve residents for age 60 and above. This is an initial application. LPA met with Tiffany Vander Poorten, applicant/ administrator. The requested capacity is six (6). No resident at the time of visit. Facility has an approved Dementia Care Plan. Hospice waiver is approved for six (6). Fire clearance: Fire clearance was granted on 08/01/24 for six (6) non-ambulatory and zero (0) bedridden. Fire clearance and Dementia care plan are in place. Auditory device is installed at all exits and operable. Bedroom#1 and #2 are approved for one (1) non- ambulatory in each room. Bedroom #3 and #4 are approved for two (2) non- ambulatory in each room. Garage in not approved for residents or staff residence. Structure: The property is a single-family residence located in a neighborhood, consisting of four (4) bedrooms, two (2) full bathrooms, one (1) half bathroom, kitchen, dining room/living room with TV, laundry room, family room, administrator are at the kitchen, and detached garage. Passageways, walkways and patios are free from obstructions. The entrance and side areas are free of hazards and debris. Garage is not accessible to residents. Bedrooms and Bathrooms for Residents: Bedrooms have nightstand, adequate lighting, adequate closet and drawer space. Bedrooms are spacious and allow for easy passage between and comfortable for usage. (- Continued on LIC 809 C -) Toilet, wash basin, bathtub/shower in bathrooms are operable. Bedrooms are accommodated for residents. Grab bars are maintained for each toilet, bathtub and shower. Linens & Hygiene Supplies: Sufficient linen/supplies which include pillowcases, mattress pads, blanket and bedspreads are available. Adequate supply of linen, wash clothes and towels are observed. Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Dishwasher in kitchen properly installed and functioning. Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet in the kitchen and inaccessible to residents. Food supply consist of two days of perishable and two weeks of non-perishable was observed. Medications, First-Aid Kit & Book: Medication cabinet is installed with a lock and inaccessible to residents. First aid kit has a thermometer, tweezers, scissors, antiseptic, bandages, and gauze. First Aid manual from American red cross was available for staff use and inaccessible to residents. Smoke Detectors: Dual Smoke /carbon monoxide detectors are tested and operable. They are located in hallways and each bedroom. Appliances: Stove burners, oven, microwave, washer, and dryer working. There are two refrigerators, located in the kitchen and garage. Each refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The residence is equipped with central air and heat. (-Continued on LIC 809 C -) Toxins: Poisons, toxins, and cleaning supplies are locked and inaccessible to residents. They are stored separately from food source. Emergency Phone Numbers, Exit Plan, Signages and posters: Emergency Disaster Plan and Labor law poster are posted. Exit Plan are available for review. Outdoor activity area in backyard: Outdoor activity area is furnished with chairs and table and in compliance. Shaded area in the backyard at the outdoor activity area is provided. Residents & Staff Files: Locked cabinets for records of staff and residents are installed and available. Residents file are observed. Applicant will not handle cash resources for residents. Water Temperature: Tested at 117.6 degrees Fahrenheit. Menu and phone: Menus are available for review. Free landline telephone is available for residents’ use and operable. Fire extinguishers: Fire extinguishers are available in the facility. They are fully charged. Reading Material, Games, Equipment & Materials: The facility has recreational materials for the residents’ use and commensurate with the plan of operation. Pool: No bodies of water located at the facility. (- Continued on LIC 809 C -) Finding: No issue was observed during today’s visit. Exit: Exit conference was conducted. Component III orientation was conducted during this visit. A copy of this report was provided to applicant. LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, s/he has been instructed to communicate with the CAB Analyst who assigned to his/her application.the state’s words, verbatim · CDSS document, Oct 15, 2024

Type of visit: Office

COMP II by CAB successfully completed Method: Phone Call at CAB Applicant/administrator participated in COMP II at CAB telephone call with analyst at CAB. Identification of the applicant and administrator was verified by presenting photo ID via phone. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Nov 15, 2023