The facility is a single-story building licensed to serve six (6) ambulatory residents, of whom six may be non-ambulatory, with a hospice waiver for four residents. LPA inspected the physical plant, including the common areas, kitchen, dining room, resident bedrooms, bathrooms, laundry room, garage, staff office, and outdoor courtyards to ensure compliance with Title 22 regulations. The facility was observed to be free of odors but unclean and not in good repair. Resident bedrooms were appropriately furnished with proper bedding and lighting. LPA observed the kitchen to contain a sufficient supply of food: a seven-day supply of non-perishables and a two-day supply of perishables; however, LPA observed a lock attached to the refrigerator and was informed by Staff 1 (S1) that the refrigerator is occasionally locked due to a resident who wanders and opens the refrigerator at night. Smoke and carbon monoxide detectors were in compliance, and fire extinguishers located in the kitchen, dining area, and hallway were last serviced on 09/26/2024. A public telephone was available in the common area and kitchen, and the required postings were present. The thermostat read 72°F, within the required range of 68–85°F. LPA observed unlocked and accessible toxins under the kitchen sink, as well as unlocked sharp knives in a kitchen cabinet.

CONTINUED 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.

During the inspection, seven residents were present in care. During the facility tour with the administrator, LPA observed an individual lying in a bed in staff room #4, with S1 seated nearby supervising. When LPA inquired about the individual’s identity, the licensee/administrator stated that the person was S1’s grandmother, who visits the facility to help babysit S1’s son. When questioned about the diapers and clothing in the room, the administrator claimed they belonged to the grandmother and provided a name. Later in the visit, the individual exited the room, and LPA conducted an interview. It was determined that the individual was, in fact, a resident in care. Residents R6 and R7 were observed in bedroom #6. R1 and R3 were at the hospital, and R5 was out in the community. LPA observed the emergency gate on the right side of the facility locked with a padlock, and the emergency gate on the left side missing the required pull-string handle for the gate latch. LPA also observed a baby gate installed at the doorway of bedroom #3 to prevent the resident from leaving the room due to concerns about disturbing others or injuring themself. Additionally, a camera was observed on the dresser in bedroom #2, facing the resident’s bed, used for monitoring due to fall-risk behaviors.

LPA will return at a later date to complete the post-licensing inspection. Based on today’s visit, the facility is not in compliance with Title 22 regulations. Deficiencies are documented on the LIC 809-D. An exit interview was conducted with Administrator Mubeezi, and copies of the LIC 809, LIC 809-D, and Appeal Rights were provided.