At approximately 10:45a.m., LPA and Administrator conducted a physical plant tour. Required postings were observed in the hallway. The smoke alarms are operational and are in each bedroom, the hallway and kitchen. There are several carbon monoxide detectors that function properly. The fire extinguishers are in the kitchen and the hallways. The charge date is 03/31/2025. During this visit facility temperature was 74 degrees Fahrenheit. The facility is fire cleared for six (6) non-ambulatory residents; one (1) maybe bedridden; approve for two (2) hospice waivers. Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrapped, dated, and stored properly as well. Knives were stored in a locked cabinet in the kitchen. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away in the kitchen. Staff office space is beside the kitchen.Bedrooms: There were six (6) bedrooms designated for residents' use. Bedroom #1, bedroom #2, bedroom #3, bedroom #4, bedroom #5, and bedroom #6 are all private use that has only one resident. Resident’s bedrooms were properly furnished with appropriate dresser, bedding, and linens with sufficient lighting. Bathrooms: There are three and a half (3.5) bathrooms designated for residents' use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 105.9 degrees Fahrenheit for half bathroom located in the hallway beside the kitchen. Bathroom #1 in inside bedroom #6, hot water measured at 115.2 degrees Fahrenheit.

Cont. to 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.

Bathroom #2 is beside bedroom #2. Hot water temperature was measured at 110.5 degrees Fahrenheit. Bathroom #3 is located inside bedroom #3, hot water measured at 112.2 degrees Fahrenheit. There was enough clean linen available in the cabinets in the hallway. Common Areas: LPA toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits six (6) chairs. LPA observed common areas to be very clean and tidy. LPA observed the floors to be in very good condition. No obstructions and/or tripping hazards throughout the facility. Furniture in common areas was observed to be in good repair. Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does have a swimming pool, fenced up and locked. Attached garage and is used for PPE and extra food storage. Laundry Service: There are enough linen available to change weekly or more if needed. Cleaning supplies are being stored in a locked cabinet in the laundry area and garage. Medications: There are in a centrally stored and locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the residents’ doctor. First Aid Kit and Book: Several first aid kits have been inspected and have the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, first aid manual are updated and it's available for staff use but inaccessible for residents. Staff Files: Records were checked for expired or missing certificates and clearances: LPA conducted a file review of four (4) staff for training, criminal record clearances and current Cardiopulmonary Resuscitation (CPR) certificate. The administrator file was reviewed for current first aid and administrator certificate. Staff files were complete at the time of this visit.Resident Files: Records were checked for requirements and legibility: LPA conducted a file review of six (6) resident records to ensure compliance with licensing forms. Resident records were complete at the time of this visit.

No immediate health and safety hazard is noted during this visit.

An exit interview was conducted. A copy of this report was provided to the Administrator.