At 11:55 AM, the LPA initiated a walk-through of the facility, accompanied by the administrator.

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

The LPA inspected the dining area and observed it clean, with all the furniture in good repair. There was a dining table and enough chairs to accommodate all the residents. The LPA inspected the fire extinguisher mounted on the wall between kitchen and living room and found it was fully charged with a last service tag of 10/02/2024. The administrator tested the smoke and carbon monoxide detector located in the hallway 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.

There are (5) bedrooms and (2) bathroom designated for residents' use and (1) bedroom designated for staff. (4) resident bedrooms are private and (1) bedroom is shared occupancy. LPA inspected all (5) resident rooms and found them clean, well-lit, and equipped with the required furniture.

At 12:06 PM, LPA inspected the common resident bathroom and found it clean, sanitary, and in good working condition. It contained soap, grab bars, a trash can, non-slip flooring, a shower chair, and a raised bathroom seat. The hot water temperature at the sink faucet was measured at 144.5°F.

Continued on LIC 809-C

At 12:22 PM, LPA inspected the garage and observed a freezer. The garage was observed cluttered with boxes, Incontinence supplies, furniture, food supplies, and mattresses. LPA inspected the laundry room and observed a washer and dryer.

At 12:34 PM, The LPA reviewed (2) staff personnel records and (3) resident records. The LPA observed that 3 of 3 residents had the Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, and CSDMR. LPA reviewed that 2 of 2 staff members didn’t have current first aid certificate. LPA reviewed that 1 of 2 staff members is not associated with the facility.

The LPA observed a locked centrally stored medication cabinet located next to the dining area. Medications were organized in separate bins for each resident. All medication bottles were properly labeled. Centrally Stored Medication Records (CSMR) were reviewed and found to be complete. The LPA inspected the first aid kit and observed it fully stocked.

At 12:58 PM, the LPA was not able to review Emergency Drill Logs as the Administrator was not conducting emergency Disaster Drills quarterly.

The following updated forms are requested to be submitted to CCLD by 12/23/2024:

• LIC 500: Personnel Report
• LIC 308: Designation of Facility Responsibility
• Certificate of Liability Insurance
• Administrator Certificate(s)

An exit interview was conducted, and Plans of Correction were reviewed and developed with the Administrator. A copy of this report and appeal rights were discussed and left with the Administrator, Michelle Benitez, whose signature on this form confirms receipt of these documents.