Beginning at 11:00AM, the LPA, along with the Administrator 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 with purchased date of 07/24/2024. Carbon monoxide and Hardwired smoke alarms were tested and all were functional at the time of the visit. LPA observed exit alarms by all doors which were functional at the time of the visit.

KITCHEN: LPA inspected the kitchen. Knives are locked in a drawer and cleaning supplies are stored inaccessible in a locked cabinet under the sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of 2 (two) days perishable and 7 (seven) days non-perishable food. Food was stored at appropriate temperatures.

BEDROOMS: There are 7 (seven) total bedrooms in the facility; 6 (six) are designated as private resident rooms and 1 (one) is designated as a staff room. All 6 (six) resident bedrooms have exits to the exterior. Bedrooms #2, #5, and #6 have private bathrooms. All resident rooms are appropriately furnished and lighting in the rooms appeared adequate. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. The bedrooms were large enough to allow for easy passage. 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.

GARAGE: The LPA toured the locked garage. The garage has a washer and dryer, locked cleaning supplies, an additional refrigerator and freezer, an emergency water supply, and an additional pantry for extra food.

COMMON AREAS: This includes the living room, dining room, and activity room areas. LPA observed common areas to be clean and properly furnished at the time of the visit.

OUTDOOR SPACE: The backyard has covered patio areas 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. LPA observed a locked storage shed in the backyard. LPA observed a latched self-closing side gate, as is required.

RECORD REVIEW: LPA began record review at 11:30 a.m. The LPA observed documentation of Infection Control Plan, Emergency Disaster Plan and last emergency drill (conducted on 05/14/25). The LPA reviewed four (4) out of four (4) resident files and 3 (three) staff files 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. The following was observed: Resident 1 (R1) did not have a signed Physician's report on file, R1 was recently admitted, went to a doctor's appointment today and will obtain their physician report. R2 needs and service plan is overdue by a month, and R3 had a negative TB checked off on their LIC602, with note "ask them for documentation, and was told it was negative. Otherwise All resident and staff files were complete and had no missing documents.

MEDICATION REVIEW: Medications for 2 (two) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit. The first aid kit was complete.

INTERVIEWS: During today's visit, LPA interviewed two (2) staff and one (1) resident. No immediate concerns were voiced.

During today's visit, LPA obtained a copy of the facility's liability insurance, staff and resident rosters.

No deficiencies were cited. Exit interview conducted and report provided.