LPA conducted the physical plant tour to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The fire extinguishers appeared fully charged and were purchased 4/1/2024. The hardwired smoke detectors and the carbon monoxide detector were tested and functional at the time of the visit. No fire clearance concerns were observed.

KITCHEN: LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of non-perishable and perishable food. Cleaning supplies are located in a locked cabinet under the kitchen sink. Knives are stored in a locked drawer. Water temperature was 105*F.

COMMON AREAS: This includes the living room and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. The laundry room door leading to the garage was locked. The garage contains more perishable food, water, PPE, incontinence supplies and cleaning supplies.

BEDROOMS: There are eight (8) total bedrooms in the facility; six (6) bedrooms are designated for resident use and two (2) for staff. The staff rooms are kept locked. All resident rooms were observed to be furnished appropriately with clean linens and sufficient lighting.

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 two (2) bathrooms for resident use. Bathrooms were observed to be equipped with nonskid mats and grab bars. The water temperature was measured at 105*F.

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: Staff and resident records were reviewed 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. Three staff files and five resident files were reviewed and in compliance with regulations. All training were observed to be complete.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: 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 usually conducted quarterly. In 2024 they conducted the drills quarterly. In 2025, there were staff away on vacation so the first drill was postponed to April. The administrator plans to conduct drills in April and June to catch up. The facility's emergency disaster plan was observed to be complete, however it has not been updated with the new administrator's information.

MEDICATION REVIEW: Medications for two (2) residents were reviewed. Medications observed were labeled, stored, and properly documented at the time of the visit. Medications appear to be given as prescribed.

INTERVIEWS: LPA attempted interviews with two (2) residents. LPA interviewed two (2) staff. No concerns noted.

No deficiencies cited. Exit interview conducted. A copy of today's report was provided.