At approximately 10:00 a.m., the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations. The following was observed:

Kitchen: The LPA inspected the kitchen/food service area at approximately 10:03 a.m. Knives and sharps were observed locked and inaccessible in a kitchen cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. At 10:06 a.m., the hot water temperature in the kitchen faucet was measured at 118.5 degrees Fahrenheit.

Common Areas: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The LPA observed a fire extinguisher to be fully charged and serviced on 03/15/2025. Required postings were observed throughout the common space. There is a working telephone on premises. Activities were observed in the living room. Auditory alarms were observed functioning during the inspection.

Report Continued on LIC 809C...

• 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.

Restrooms: There are two (2) restrooms for residents’ use. The first bathroom is located by the main hallway, and the second bathroom is located in bedroom #4. Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 10:12 a.m., the hot water temperature was measured, and it was found to be within the required range of 105 – 120 degrees Fahrenheit at the time of the visit. Personal hygiene items were observed locked and inaccessible to residents at the time of the inspection.

Bedrooms: There are four (4) bedrooms for resident use. Two (2) bedrooms are designated as private / single occupancy, and two (2) bedrooms are designated as a double / shared occupancy. Resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. There is a closet with additional clean linens and towels for resident use. The LPA observed a staff bedroom on premises inaccessible to residents at the time of the visit.

Garage: The washer and dryer were observed inside the garage. Detergents and cleaning supplies were observed locked and inaccessible during the inspection. The LPA observed an adequate amount of emergency food and water; properly stored. A second refrigerator was observed in the garage with additional food for residents in care.

Outdoors: The backyard has a covered patio area with patio furniture adequate for resident use. There is one (1) side gate with self-latching mechanisms. All passageways were observed to be clear of any obstructions. No bodies of water noted at the time of the visit.

Report Continued on LIC 809C...

Four (4) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All files were in order.

Five (5) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All files were complete.

The Administrator’s Certificate is valid until 05/21/2026.

Emergency Disaster Planning: During today’s visit, the LPA reviewed the facility's emergency disaster plan, which was observed to be complete. Emergency disaster drills conducted quarterly as per regulation; the last fire drill was conducted on 09/22/2025.

Medications: Medications review began at approximately 12:15 p.m. Medications are centrally stored and kept in a locked cabinet by the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Four out of four residents’ medications were observed and reviewed. Medications appear to be given as prescribed at the time of the inspection.

Exit interview conducted. A copy of report was provided.