Beginning at 09:41AM, the LPAs, along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

Fire extinguisher was fully charged and serviced on 07/12/2023. Combination smoke and carbon monoxide detectors were tested at 10:06AM and all were functional at the time of the visit. No fire clearance concerns were observed.

BEDROOMS: There are 5 (five) total bedrooms in the facility; 2 (two) are designated as shared rooms, 2 (two) are designated as private resident rooms and 1 (one) is utilized as a staff room. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Room #4, which belongs to Resident #1 (R1) was observed to have full bed rails. Room #5, belonging to Resident #2 (R2) contained a fireplace that was observed to be inaccessible to residents, the resident’s bed was also observed to have full bed rails.

BATHROOMS: There are 2 (two) bathrooms for resident use. Restrooms were observed to contain nonskid mats. Grab bars were observed in the bathrooms. Water temperature was measured in bathroom 1 (one) at 09:45AM and was observed to be 118.8F. Water temperature was measured in bathroom 2 (two) at 09:52AM and was observed to be 115.2F. Both bathrooms were measured within the required range.

Report Continued on LIC 809-C

OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs

KITCHEN/GARAGE: The LPAs observed the garage to contain locked cleaning supplies, emergency food, additional refrigerator/food storage, as well as supplies and laundry machines. 3 (three) bags of beans designated as emergency food were observed to be expired. Expired food was disposed of at 10:03AM. Kitchen was observed to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. Cleaning supplies are located in a locked under-sink cabinet. Knives were stored securely in a locked drawer.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPAs reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly, with the last drill conducted on 04/15/2024.

RECORD REVIEW: Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 3 (three) staff files observed contained all documents. 2 (two) resident files were reviewed and both contained all documents.

MEDICATION REVIEW: Medications for 2 (two) residents were observed. At 11:48AM, R2’s medication bin was observed to contain unlabeled Albuterol Sul quantity 2. R2 has PRN prescribed however it has not been started yet. Staff disposed of unlabeled medication at time of visit.

INTERVIEWS: During today's visit, LPAs interviewed 1 (one) staff and attempted to interview 2 (two) residents both of which were non-verbal.

During today's visit, LPAs obtained a copies of the personnel report (LIC500), client roster (LIC9020), and the facility's liability insurance.

Report Continued on LIC 809-C

Exit interview conducted, report issued, and appeal rights provided.