Beginning at 11:15AM, the LPA, along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

COMMON SPACES/AMENITIES: Common areas include the living room and family room. Common areas were appropriately furnished and in good condition. There is a functioning telephone on the premises. Emergency exiting plans/sketch, emergency telephone numbers, and required postings are posted in the entryway.

BEDROOMS: The facility has six (6) bedrooms of which four (4) are designated for single-resident use, one (1) is designated for shared-resident use, and one (1) is a staff room. Staff room remains locked at all times. All bedrooms were furnished appropriately with clean linens, furnishings, and sufficient lighting. All bedrooms have exits to the exterior with functioning auditory exit alarms. Administrator stated permits were secured to convert one resident room to a resident room and a staff room. Documents were submitted to CCL upon completion of construction earlier in the month. LPA Dulek will follow up with the case-LPA related to these documents and fire clearance.

BATHROOMS: The facility has five (5) bathrooms; three (3) are for resident use and two (2) are for staff use. LPA observed resident restrooms to be equipped with grab bars near the toilet and shower/tub and

Report continued on LIC 809-C.

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

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 directly outside the sliding doors from the living room. No bodies of water were observed on the premises. The facility has a self-latching and self-closing exit gate located on the side passageway.

KITCHEN/GARAGE/LAUNDRY: Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. Knives and sharps are stored inaccessible. Cleaning supplies are not stored in the kitchen. LPA observed a fire extinguisher in the kitchen that was fully charged and last purchased 10/19/2024. During today's visit, Administrator purchased new fire extinguisher. LPA toured the locked garage attached to the kitchen. LPA observed an additional refrigerator/freezer, a washer and dryer, cleaning supplies, and emergency water supply.

RECORD REVIEW: Beginning at 11:41AM, LPA began record review. LPA reviewed six (6) out of six (6) resident and five (5) out of five (5) personnel files for documents including but not limited to: resident bed rail orders, resident Admission Agreement, TB test, health screening, staff training and fingerprint clearance. All resident files and staff files were in order.

MEDICATION REVIEW: Medications are centrally stored in the kitchen and inaccessible. At 01:59PM, LPA reviewed medications for two (2) residents. All medications reviewed were properly documented and appeared to be administered as prescribed.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's emergency disaster plan and infection control plan. Administrator stated that emergency disaster drill was last conducted in spring 2025. Administrator stated going forward, emergency disaster drills will be conducted quarterly. Administrator will update the document and send to CCL.

No citations issued. Exit interview conducted. A copy of today's report was provided.