The LPA and staff / 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.

COMMON AREAS: This includes the living room, and dining room. At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 12:01 p.m., hardwire combination of smoke / carbon monoxide detectors and fire door were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 11/14/2025. The emergency exiting plans/sketch are posted. The emergency telephone numbers are posted in the common hallway. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 10/04/2025 and are conducted quarterly. Activities were observed in the common areas. The fireplace in the living room was adequately screened. There is a functioning telephone on the premises. Auditory alarms at the entrances and exits were observed and functional at the time of the visit. LPA observed surveillance cameras installed in the common areas of the facility. The Administrator presented the live monitoring screen to the LPA, confirming that all cameras were functioning properly and that none of them were equipped with audio capability.

Report Continued on LIC 809-C PAGE 2...

• 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.

INTERVIEWS: Starting at 9:55 a.m. and throughout the visit two (2) staff and two (2) resident interviews were conducted. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interview revealed that no concerns were noted or voiced at the time of the visit.

BEDROOMS: There are eight (8) total bedrooms in the facility; six (6) bedrooms are designated as private, single occupancy, resident rooms and two (2) staff rooms. The staff rooms are kept locked at all times and observed to be occupied by staff. Five (5) out of six (6) resident rooms have exits to the exterior. All passageways were observed to be clear of obstructions. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

RESTROOMS: There are three (3) total restrooms. Two (2) are designated as a shared / common resident restroom, and One (1) is designated as a private resident restroom. Resident restrooms were observed to be equipped with a slip resistant surface / mat. Grab bars were observed in the restrooms. The restrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in all resident restrooms and ranged between 105.0 - 112.5 degrees Fahrenheit, all within the required range. LPA observed storage space closets in hallway containing extra clean linens and towels for resident use.

KITCHEN: The LPA inspected the kitchen/food service area at 10:18 a.m. Knives and sharps were observed in a locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 112.1 degrees Fahrenheit at 10:19 a.m. Cleaning supplies and other chemicals are kept locked under the sink, the hallway chemical closet and in the garage locked and inaccessible to residents in care.

GARAGE: LPA observed the attached garage accessible through the kitchen, which was locked at the time of the visit. LPA observed emergency food and water, personal protection equipment (PPE) , incontinent supplies, and an extra refrigerator/freezer that was checked for proper labels and expiration dates. LPA observed laundry units and laundry detergent. LPA observed a storage closet with supplies.

Report Continued on LIC 809-C PAGE 3...

RECORDS: Resident Records: were reviewed beginning at 10:32 a.m. six (6) 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 records were in order. Personnel Records were reviewed beginning at 11:33 a.m. five (5) Personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

INFECTION CONTROL/ EMERGENCY DISASTER PLANNING: During today’s visit the LPA reviewed the facility’s infection control practices and the facilities emergency disaster plan. Both documents were observed to be complete and updated annually as required. The facilities policies and procedures, as they pertain to infection control and emergency planning meet the regulatory standard.

MEDICATIONS: Medication review began at approximately 12:05 p.m. Medications are centrally stored and locked in a cabinet in the kitchen adjacent to the dining room. Medications for three (3) residents were reviewed. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. No errors observed during review. LPA observed the first aid supplies to be complete, including a thermometer and a current version of a first aid manual.

DOCUMENTS: Documents obtained during the visit include: LIC 500 facility roster and LIC 9020A Resident roster and copy of the Limited Liability insurance.

During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. Exit interview conducted. Copy of report reviewed and provided.