The LPA inspected the food service area and observed that knives/sharp instruments are stored in drawers inaccessible to residents. All appliances were in operable condition and looked clean/in good repair. Appliances such as microwaves, refrigerators, stoves, etc. are clean and operating properly. Food utensils, dishes, glasses, etc. are clean and in good repair with no cracks or chips. Furniture is room/resident appropriate, clean and in good repair. All rooms are appropriately furnished for their intended use such as bedrooms, dining rooms, kitchens, living rooms, etc. Hot water temperature is maintained at an appropriate temperature Fahrenheit as per Community Care Licensing (CCL) Title 22 regulations. Outdoor activity spaces have shaded areas and furnished for outdoor use. Each resident has an adult bed with a mattress, pad, bedsprings, and pillow, which are clean and in good repair. Each bed is fitted with sheets, pillowcase, blankets, and bedspread that are clean and in good repair. Each resident has adequate dresser and closet space for clothing and other belongings that includes at least two drawers or adequate dresser space. The facility has a sufficient supply of linens to permit weekly changing or more often to always insure clean linens for residents. Equipment and supplies for resident personal hygiene is available and on site. Activity supplies are available for residents. As the facility has an approved fire clearance for a maximum of six (6) residents, there is no signal system required or observed by LPA. Refrigerators and freezers are maintained at an appropriate temperature Fahrenheit as per Community Care Licensing (CCL) regulations. Food storage and preparation areas, including pantries, cupboards, counters, etc., are clean and appropriate for food preparation. Continued on 809-C

At the time of the visit, all common areas/interior rooms of the facility were observed to be appropriately furnished, with all furniture in good condition. There are activity materials in the common areas of the facility in good repair and operating condition. The facility maintained a comfortable temperature in all areas inspected. There is one (1) fireplace in the facility that is adequately screened and inaccessible to residents. There is appropriate lighting in all the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, with no changes in incline requiring ramps and/or sturdy hand railings/stair chair accessibility devices. The facility maintains an auditory alert system/delayed egress system on all exits from the interior of the facility. There are ramps in place on all exits out of the facility with changes in incline. This facility is one (1) story throughout and therefore there are no stairways for residents to utilize. There are no bodies of water as observed by LPA in the outdoor area of the facility. LPA did not observe any noticeable outdoor hazards. The outdoor activity space is completely enclosed by fencing/walls and latching gates. The front outdoor area of the facility consists of a front courtyard area and the garage contains storage of emergency supplies. The designated laundry area is in a locked addendum/closet area in a hallway of the facility, with the storage of cleaning products locked and inaccessible to residents, away from food products. There was emergency food and water in cabinets in the living room/dining room area of the facility, which was observed to be in good condition. Cleaning supplies, disinfectants, and other items that could pose a danger to residents are kept in areas inaccessible to residents.

The facility restrooms were sanitized and in operating condition while the LPA toured the facility. All resident restrooms in the facility that included soap, paper towels, required postings, and clean trashcans with closed lids. Continued on 809-C

An emergency exiting plan and emergency phone numbers are posted in an appropriate place. A current disaster and mass casualty plan maintained at the facility. First-aid supplies, which include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual, are maintained. Administrator’s records, employees and resident records are maintained at the facility and available for review by the LPA as employees are hired and residents accepted into the facility. The facility complies with CCL standards for health screening, TB clearance, staff training, criminal background clearance and transfer requests. Admission agreements and needs and services (ANS) plan are maintained for each resident and/or their authorized representative. Resident records are maintained on the facility premises in a secured area. Centrally stored medications are locked and inaccessible to residents. LPA audited the medications for residents and noticed no irregularities or issues concerning the dispensing of medications or the logging of medications. The medications in the facility were labeled appropriately with no additional or prohibited markings by the facility. The facility administrator meets the qualifications as specified in Title 22 regulations. Administrator has a current Residential Care Facility for the Elderly (RCFE) administrators’ certificate that expires on 04/01/2026. The facility maintains documentation on site prominently posted in areas accessible to residents and their visitors. Provider Information Notices are available and able to be presented to Staff, residents, visitors, and accessible to LPA.

Exit interview conducted by LPA. Copy of this report provided to the facility.