LPA and staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The LPA inspected the kitchen/food service area at 10:31AM. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for expiration dates; food labels had expiration date clearly marked. Knives and sharps are stored locked and inaccessible to residents in care.

BEDROOMS: There are five (5) resident bedrooms. Four (4) bedrooms are single occupancy, and one (1) bedroom is double occupancy. The LPA observed the resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There is a locked staff room on the premises by the garage.

RESTROOMS: There are two (2) resident restrooms. The first restroom is located in the hallway and the second restroom is located in Bedroom #1. Restrooms were clean, sanitary, and in operating condition with grab bars and slip-resistant surfaces. Hot water temperatures were measured in restrooms and were between 113.0-118.4 degrees F, which is within the required range.

Report Continued on LIC 809C.

• 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.

OUTDOORS/GARAGE/LAUNDRY: The garage is kept locked at all times. The facility has an adequate supply of emergency food and water which was observed to be in good condition. The washer and dryer were observed inside the garage inaccessible to residents in care. Detergents and cleaning solutions were observed locked and inaccessible. The backyard has a covered outdoor area equipped with furniture for resident use. Emergency exits and passageways were observed free of obstruction. There is one (1) self-latching gate. No bodies of water were noted at the time of the visit.

RECORD REVIEW: Beginning at 11:15AM, LPA reviewed six (6) out of six (6) resident and four (4) personnel files for documents including but not limited to: medical records, care plans, resident Admission Agreement, TB test, health screening, staff training, and fingerprint clearance. All resident and personnel files were in order.

MEDICATIONS: At 12:20PM, LPA reviewed medications for two (2) residents. Medications are centrally stored and locked in a cabinet by the kitchen area. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs were properly documented and logged. Medications were observed to be properly documented on the centrally stored medications and destruction record and were in compliance with regulation, state, and federal law.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency drills are conducted quarterly as required, with the last drill conducted on 11/02/2025.

Exit interview conducted. No deficiencies issued. A copy of the report provided.