At 11:00 a.m. the LPA conducted a tour of the physical plant with the ED to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a four (4) story residence that consists of assisted living units on all floors and a memory care unit on the second floor. The LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced 07/18/2024. Smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed required postings near the mail room hallway. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit.

COMMON AREAS: The LPA toured all four floors and common spaces in both the assisted living and memory care unit. Activity rooms and common spaces were clean and in good repair. The facility maintained a comfortable temperature. The LPA observed the stairwells and they each had an emergency evacuation chair.

BEDROOMS: The LPA observed ten (10) randomly selected resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. Bedroom #249 was observed with a lot of dirt/crumbs on the carpet. Bedroom #233 was observed with a lot of dirt/crumbs on the carpet. Report will continue on LIC809-C, 2nd page.

RESTROOMS: Almost all resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. Restroom in bedroom #233 and #238 and had a sticky floor. The hot water temperature was measured in resident rooms (#112, 254, 225, 239, 249, 233, 238, 304, 408) ranged between 105.8– 111.7*F. At 11:28 a.m. the LPA observed prescribed medication in the bathroom of room #112, however resident in the room cannot administered medications per their LIC602. At 12:01 p.m. the LPA observed a bottle of hydrogen peroxide in the bathroom of room #239 in MC. At 12:43 p.m. the LPA observed a bottle of Miralax, a container of Hempvana maximum strength pain relief cream, a prescribed Calmoseptine ointment, and a bottle of toilet bowl with bleach in the the bathroom of room #304. Resident in room 304 cannot administer or store medication per their LIC602. At 12:55 p.m. the LPA observed a container of Comet with Bleach, a bottle of Clorox disinfecting cleaner, and 2 containers of disinfecting wipes in the bathroom of room#408.

OUTSIDE GROUNDS: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for resident’s use. No pool on the premises. Parking is available for residents and visitors. At 11:57 a.m. the LPA observed a hose in the memory care court yard.

Interviews: The LPA interviewed two (2) residents. No immediate concerns were voiced.

Record Review: At 1:45 p.m. a review of facility files was initiated. Facility records are stored in a locked office. The LPA observed documentation of Infection Control, and Disaster prevention. The LPA obtained Client Roster, Staff Roster, and Insurance Liability. The LPA reviewed five (5) of ninety-three (93) resident files. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. Due to time constraints, the LPA will return at a later date to complete the inspection.