The LPA and Administrator 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 facility is a single-story home located in a residential neighborhood.

COMMON AREAS: This includes the living room, and dining room. At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 1:37 p.m., hardwire combination of smoke / carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 03/17/2026. The emergency exiting plans/sketch are posted in every room. The emergency telephone numbers are posted in the common hallway. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 03/17/2026 and are conducted quarterly. Activities were observed in the common areas. There is a functioning telephone on the premises. Auditory alarms at the entrances and exits were observed and functional at the time of the visit.

INTERVIEWS: Throughout the visit one (1) staff and two (2) resident interviews were conducted. Staff interview revealed that staff is knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interviews revealed that no concerns were noted or voiced at the time of the visit. Report Continued on LIC 809-C PAGE 2...

• 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.

BEDROOMS: There are nine (9) total bedrooms in the facility; six (6) bedrooms are designated as private, single occupancy, resident rooms and three (3) staff rooms. The staff rooms are kept locked at all times and observed to be occupied by staff. Six (6) of six (6) resident rooms have exits to the exterior. All passageways were observed to be clear of obstructions. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

RESTROOMS: There are seven (7) total restrooms. Six (6) are designated as private resident restrooms located in the resident rooms. One (1) is designated as guest / staff restroom. Resident restrooms were observed to be equipped with a slip resistant surface / mat. Grab bars were observed in all the restrooms. The restrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in all resident restrooms and ranged between 105.2-111.9 degrees Fahrenheit, all within the required range. LPA observed storage space closets in the hallway containing extra clean linens and towels for resident use.

KITCHEN: The LPA inspected the kitchen/food service area. Knives and sharps were observed in a locked drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 111.9 degrees Fahrenheit within the required range. Cleaning supplies and other chemicals are kept locked under the sink inaccessible to residents in care.

GARAGE / OFFICE: LPA observed the facility garage adjacent the staff bathroom which was locked at the time of the visit. The garage is used as an office area which contained emergency food, water, emergency supplies, an extra refrigerator/freezer that was checked for proper labels and expiration dates. LPA observed a washer and dryer along with detergent.

RECORDS: Personnel Records. Five (5) Personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

Report Continued on LIC 809-C PAGE 3...

RECORDS: Resident Records Five (5) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, Home Health records, Hospice records, PRN authorization letters, and current needs and services plan. All records were in order.

INFECTION CONTROL/ EMERGENCY DISASTER PLANNING: During today’s visit the LPA reviewed the facility’s infection control practices and the facilities emergency disaster plan. Both documents were observed to be complete and updated annually as required. The facilities policies and procedures, as they pertain to infection control and emergency planning meet the regulatory standard. Emergency disaster plan was last updated / reviewed on 02/06/2026.

MEDICATIONS: Medications are centrally stored and locked in a closet at the entrance adjacent to the living room. Medications for three (3) residents were reviewed. Medications are labeled and checked for expiration dates. All medications including PRNs were properly documented on the centrally stored medications and destruction record, stored, locked and inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed. No errors observed during review. LPA observed the first aid supplies to be complete, including sterile first aid dressings, bandages, tweezer, a thermometer and a current version of a first aid manual.

DOCUMENTS: Documents obtained during the visit include: LIC 500 facility roster and LIC 9020A Resident roster and copy of the Limited Liability insurance.

At the time if the visit the LPA reviewed the facilities contact information on file including phone numbers, email and annual fees. Administrator confirmed that all information is accurate.

No citations issued. Exit interview conducted. Copy of report reviewed and provided.