At approx. 9:30a.m. LPA Mosley conducted a tour of the physical plant with Health Services Director and Business Office Director to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was noted: Facility is a double-story residence that consists of a memory care unit, and an assisted living unit. LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced on 12/19/2023. On the initial visit on 09/28/2024 the Administrator provided a monthly fire alarm testing and inspection report done on 08/27/2024 where all smoke alarms and carbon monoxide detectors were tested and functioned properly. The last emergency disaster drill took place on 10/24/2024 and 10/31/2024 to cover both shifts and are conducted quarterly. LPA observed all required postings in the Activity Room near the entrance area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Activities observed on both units. In the Memory Care until at approx. 9:45am, morning movie was observed with about ten (10) to fifteen (15)residents in attendance. In the Assisted Living unit at approx. 11:00am. Paws for Love (therapy dog activity) was observed with about six (6) residents in attendance.

Report Continued on LIC 809C...

PERSONNEL FILES: were reviewed beginning at 10:25 a.m. for eight (8) staff including the Business Office Director, and Health Services Director. Files were reviewed for, but not limited to personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order at the time of the visit.

RESIDENT RECORDS: were reviewed beginning at 11:26 a.m. for eight (8) residents. 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 at the time of the visit.