The LPA and 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 1:20 p.m., hardwire combination of smoke / carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 08/21/2025. The emergency exiting plans/sketch are posted in every room. The emergency telephone numbers are posted at the entrance. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 05/02/2025 and are conducted quarterly with the next one scheduled this month. Activities were observed in the common areas. The fireplace in the living room was adequately screened. There is a functioning telephone on the premises. LPA observed a Ring doorbell/camera on the front entry. Licensee Representative disabled audio on the Ring camera.

INTERVIEWS: Starting at 10:18 a.m. two (2) staff and two (2) resident interviews were conducted. Staff interviews 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. Residents were pleased with the facility. 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.

BEDROOMS: There are six (6) total bedrooms in the facility; four (4) bedrooms are designated as private, single occupancy, resident rooms, one (1) is designated as double occupancy, shared, resident room and one (1) is designated as the Administrators office, which remains locked. There is no staff room and Administrator stated that staff remain awake at night. All five (5) 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 restrooms, 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 109.2-116.8 degrees Fahrenheit, all within the required range.

KITCHEN: The LPA inspected the kitchen/food service area at 11:20 a.m. Knives and sharps were observed in a locked drawer. 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 116.8 degrees Fahrenheit at 11:23 a.m. Cleaning supplies and other chemicals are kept locked under the sink area.

GARAGE /LAUNDRY ROOM: LPA observed the locked laundry room adjacent to the kitchen. Laundry room has a washer and dryer and locked cleaning supplies. LPA observed a staff break area. LPA observed a sufficient supply of emergency food and water.

BACKYARD: The entire property is fenced. The backyard has a covered patio area with shade, patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed two (2) self-latching gates. There were no bodies of water noted at the time of the visit. There is a locked storage shed in the back yard inaccessible to residents. Two (2) pathways used as an emergency exit were free of obstructions at the time of the visit.

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

Resident Records were reviewed beginning at 11:29 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 12:23 p.m. Four (4) 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. The facilities policies and procedures, as they pertain to infection control and emergency planning, adhere to the standard.

MEDICATIONS: Medication review began at approximately 1:00 p.m. Medications are centrally stored and locked in a cabinet in the kitchen adjacent to the dining room. Medications for five (5) 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.

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.