KITCHEN: The LPA inspected the kitchen/food service area at 9:56 a.m. Knives and sharps were observed in a locked cabinet under the sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 107.2 degrees Fahrenheit at 9:57 a.m.

INTERVIEWS: At 10:07 a.m., 10:12 a.m., and 10:22 a.m., Three (3) resident interviews were conducted during the inspection. Resident interviews revealed that no concerns were noted or voiced at the time of the visit. At 1:55 p.m. one (1) staff interview was conducted, Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. No concerns noted at the time of the visit.

Report Continued on LIC 809C PAGE 2...

• 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.

COMMON AREAS: At the time of the visit, furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. At 11:12 a.m., smoke detector(s), fire doors and carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguishers were observed and fully charged on 12/17/2024. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 03/14/2025 and are conducted quarterly. Activities were observed in the common areas. An adequate supply of emergency food and water was observed. The facility has a working telephone on premises. Auditory alarms on all doors were functional at the time of the visit. Entry/exits in the home were free of obstruction. Inside temperature was maintained at a comfortable level.

BEDROOMS: The facility is a single-story residential home with six (6) bedrooms of which six (6) are for resident use. Resident bedrooms are private, single occupancy. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

BATHROOMS: The facility has a total of four (4) bathrooms. Two (2) are private resident bathrooms and two (2) are shared, common bathrooms for resident use. Bathrooms were clean and sanitary and in operating condition with grab bars and slip resistant surfaces. Hot water was measured in all resident bathrooms from 10:03 a.m. - 10:18 a.m. and measured between 107.2 – 111.7-degree Fahrenheit within the required range. The sinks had sufficient liquid soap, and paper towels. At approximately 10:09 a.m. LPA observed that the private bathroom in bedroom # 6 was an alteration and does not have a permit however the facility has submitted the proper documentation to the city for permit approval. The Administrator stated they will keep the department updated on the permit process.

OUTDOOR SPACE/ GARAGE: The LPA observed the back yard which had three (3) portable outdoor umbrellas for shade along with patio furniture including tables and chairs for resident use. The LPA observed the right-side gate that self-latches with a clear passageway in case of an emergency. There were no bodies of water observed on the premises at the time of the visit. The garage is kept locked and inaccessible to residents. LPA observed an extra freezer with extra food that was checked for proper labels and expiration dates. Laundry units observed in the garage. Cleaning solutions, laundry detergent, toxins, chemicals, and hazardous items were inaccessible and locked away in the garage. Entry/exits were free of obstructions.

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RECORDS: Records review began at 10:20 a.m., five (5) resident records were reviewed for, but not limited to: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records in order. At 10:55 a.m. two (2) Personnel records including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

Infection Control / Emergency disaster planning: During today’s visit LPA Mosley reviewed the facility’s infection control practices and the facilities emergency disaster plan. The facilities policies and procedures as they pertain to infection control and emergency preparedness are adequate.

MEDICATIONS: Medications review began at approximately 1:44 p.m. Medications are centrally stored and locked in a closet adjacent to the entrance. Medications for four (4) residents were reviewed. Medications are labeled and checked for expiration dates. All medications were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. No errors observed.

DOCUMENTS: Documents obtained during the visit include: LIC 500 facility roster, LIC 9020A Resident roster, an updated facility sketch and current Liability Insurance.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.