Beginning at 09:37 a.m., LPA along with staff, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

Fire extinguishers appeared fully charged and were last serviced on 8/26/2024. Carbon Monoxide detector was tested at 1:08 p.m. and the smoke detectors were tested at 1:10 p.m. and all were functional at the time of the visit.

KITCHEN: LPA observed the kitchen to be clean and appliances appeared to be functional. Staff were in the kitchen upon LPA's arrival, serving breakfast and cleaning. The knives were locked in a drawer. The dish soap and cleaning detergent was stored in a locked cabinet under the sink. The facility had a sufficient amount of perishable and non-perishable food.

LAUNDRY ROOM: The laundry room is adjacent to the kitchen. There are two doors leading to the laundry room which are kept locked unless staff are using the room. The emergency supply of non-perishable food and water is kept in the laundry room. Laundry detergent is kept in a locked cabinet above the washer and dryer.

COMMON AREAS: This includes the living room and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. The fireplace was screened. LPA observed cameras in the common areas.

Report Continued on LIC 809-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.

BATHROOMS: There are two (2) bathrooms for resident use and one (1) for staff use. Resident restrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed in the bathrooms. The bathrooms had toilet paper, paper towels and wipes. The hot water temperature was measured between 114.3*F - 114.4*F.

BEDROOMS: There are six (6) resident bedrooms designated for private resident use. There is also one staff room with two beds. There is another staff room at the front of the house used for storage. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Alarms were observed on resident exit doors.

OUTDOOR SPACE: The backyard has a patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. There were no bodies of water on the premises.

RECORD REVIEW: LPA reviewed all six (6) residents' files. Records were complete.

Staff records were reviewed for the two (2) primary caregivers and the administrator. All records were complete, including training records and CPR/first aid.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA 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 was complete and last reviewed by the facility representative in January 2025. Emergency evacuation drills are conducted with staff quarterly with the last drill in January 2025.

MEDICATION REVIEW: Medications for 2 (two) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit. Medications are stored in a locked hall closet.

INTERVIEWS: During today's visit, LPA interviewed 2 (two) staff and 2 (two) residents. No concerns noted.

Exit interview conducted. A copy of today's report was provided.