Beginning at 11:28 AM the LPA, along with facility 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 AREAS: This included the living room/dining area and the hallway. LPA observed the living room/dining area to contain adequate seating, a television, and activities for resident use. LPA observed a fire extinguisher mounted in the living room/dining area to be fully charged and purchased on 12/08/2025. LPA observed the hallway to be clean and free from any obstructions. The living room/dining area contained a dining table with adequate seating for resident use. The facility’s combination fire and carbon monoxide alarms were tested at 11:47 AM and were functional at the time of the visit.

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer which contained knives and other sharp objects. LPA observed a locked under-sink cabinet which contained cleaning supplies. LPA observed a complete first aid kit.

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.

BATHROOMS: There are two (2) bathrooms at the facility. One (1) bathroom is designated as a private resident bathroom, and one (1) bathroom is designated as a shared resident bathroom. Both resident bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured to be between 116.6 and 119.1 degrees Fahrenheit, which is in compliance with regulation. LPA observed both resident bathrooms to contain appropriately secured under sink cabinets which contained personal grooming supplies for resident use.

OUTDOOR SPACE: The facility has one (1) emergency exit gate located at the front of the property; LPA observed clear passageways for emergency exit use. The facility had adequate shaded seating outdoors for resident use. All emergency exits were observed to be free from obstructions.

GARAGE: The garage for the facility is attached to the back house on the property. LPA observed the garage to contain two (2) secured cabinets which contained extra cleaning supplies and laundry supplies. LPA observed two (2) secured filing cabinets which contained facility files and resident medications. Additionally, LPA observed the garage to contain the facility’s washer and dryer, extra care supplies, extra linens, and adequate emergency food and water supplies.

RECORD REVIEW: Record review began at 11:50 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Five (5) staff files were reviewed. All staff files contained the required documents and trainings. Five (5) resident files were reviewed all resident files contained all required documentation and signatures. No deficiencies were observed during record review.

Continued on LIC 809C.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 04/08/2026. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator.

INTERVIEWS: LPA interviewed one (1) resident and two (2) staff members. The resident interviewed stated that the staff treat them well and are attentive to their needs. The resident interviewed had no concerns with the facility. Both staff interviews were conducted with the assistance of the facility Administrator acting as a translator. Both staff members interviewed understood their roles and responsibilities, the resident’s rights, the different forms of abuse, and the appropriate reporting procedures for suspected abuse.

During today’s visit LPA obtained a copy of the facility’s updated emergency disaster plan, LIC 500, resident roster, and liability insurance.

No deficiencies were cited during today's inspection. Exit interview conducted and copy of the report was issued.