Beginning at 02:03PM, LPA, along with Facility Designee 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. The following was observed:

Fire extinguishers are fully charged and last serviced on 4/11/2025. During today's visit, the hardwired combination smoke and carbon monoxide detectors were tested at 03:13PM and were functional at the time of the visit. No fire clearance concerns were observed during today's visit.

KITCHEN: LPA observed the kitchen 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. Knives and all sharps are stored in a locked cabinet under the kitchen sink. All cleaning supplies are stored in a locked hallway closet.

COMMON AREAS: This includes the living room, family room, and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. The facility has two (2) fireplaces - one (1) in the living room and one (1) in the family room. Both were observed to be adequately screened.

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 three (3) bathrooms for shared resident use. Restrooms were observed to be equipped with slip-resistant surfaces. Grab bars were observed in the bathrooms. The water temperature was measured and was found to be in compliance with regulation.

BEDROOMS: There are eight (8) total bedrooms in the facility; six (6) bedrooms are designated for private resident use, one (1) staff room, and one (1) office. The staff room is kept locked. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

OUTDOOR SPACE: The backyard has a covered 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: Began at 01:04PM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident medical assessments, needs and service appraisal, and personal rights. All five (5) staff files and four (4) resident files observed were in compliance with regulation.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, 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 drills are conducted quarterly, with the last drill conducted on 12/03/2025. Emergency disaster plan was observed to be complete and updated annually, as required.

MEDICATION REVIEW: Began at 01:40PM. Medications for two (2) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit.

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