At 9:06 AM, the LPA initiated a walk-through of the facility, accompanied by the ADM.

There were (6) bedrooms and (2½) bathrooms designated for residents' use. All (6) resident rooms were single occupancy. LPA inspected all (6) resident rooms and found them clean, well-lit, and equipped with the required furniture. Storage closets with incontinence supplies were observed in every room. LPA inspected (2½) bathrooms and found them clean, sanitary, and in good working condition. The bathrooms contained soap, grab bars, paper towels, a trash can, a shower chair, and non-slip flooring. The hot water temperature at the sink faucet measured 118.1°F in bathroom #1 and 118.2°F in bathroom #2. The hallway closets were observed to contain clean linens, hand gloves, paper napkins, and towels for residents’ use.

LPA inspected the kitchen and found it clean, with no food preparation and cooking in progress at the time. The appliances were checked and observed to be in working order. The LPA inspected a locked cabinet under the kitchen sink containing knives, sharp objects, detergents and cleaning supplies. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No expired food or stored medications were noted.

Continued on LIC809-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.

LPA inspected the living room and observed it clean, with all furniture in good repair. There were sofa chairs, recliners, tables, a television, and a piano in the living room.

LPA inspected the fire extinguisher mounted on the wall in the living room and found it fully charged, with the last service tag dated 04/30/2024. The ADM tested the smoke and carbon monoxide detector located in the garage in the LPA's presence, and it was found to be functional. Additional smoke and carbon monoxide detectors were observed in all bedrooms and common areas of the facility during the visit.

LPA inspected the garage and observed a washer and a dryer, and storage cabinets. A office room was observed near the front of the facility.

LPA toured the backyard area, found ramps and passageways in good condition, clear of obstructions, with no blocking or tripping hazards. It had a set of a patio table, chairs, and shaded areas for resident use. No bodies of water were noted.

LPA reviewed six (6) staff personnel records and five (5) resident records. The LPA observed that 5 of 5 residents had an Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, and CSDMR. LPA observed that 6 of 6 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 6 of 6 staff members were associated with the facility.

LPA observed a locked centrally stored medication cabinet in the hallway next to the living room. Medications were organized in separate bins for each resident. Centrally Stored Medication Records were reviewed and found to be complete.

LPA inspected the first aid kit and found it fully stocked. Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster Drills were conducted quarterly, with the most recent drill completed on 04/14/2025.

The following updated forms are requested to be submitted to CCLD by 06/23/2025:

Continued on LIC809-C

No deficiencies were cited during today's visit.

An exit interview was conducted with the Assistant Administrator. A copy of this report was provided to the Assistant Administrator, Ofelia Guanzon, whose signature on this form confirms receipt of the report.