File Review: Beginning at 10:34AM, LPA reviewed six (6) resident records for documents including, but not limited to: medical assessment, needs and service appraisal, Admission Agreement, and personal rights. Beginning at 12:20PM, LPA reviewed five (5) staff files for documents including but not limited to: health screening, TB test, staff training records, and fingerprint background clearance. All files reviewed were complete and contained all documents.

Beginning at 11:48AM, the LPA, along with Facility Designee conducted a tour of the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of six (6) resident bedrooms and three (3) bathrooms. The LPA observed 2 (two) fully charged fire extinguishers last serviced on 09/16/2025. Hardwired combination smoke alarms and carbon monoxide detectors were tested and functioned properly during time of visit. LPA observed all required postings throughout the facility.

Bedrooms/Bathrooms: The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens

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.

Common Areas: These included the two (2) living rooms and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. The facility maintained a comfortable temperature throughout the visit.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Sharp objects are stored in a locked drawer. Cleaning supplies are stored locked under the sink.

Laundry Room: The laundry room is locked and contained laundry equipment and cleaning supplies.

Surrounding Grounds (Outdoors):The backyard has a covered outdoor area equipped with furniture for resident use. All exits were observed to be clear of hazards. Two (2) Outdoor gates were observed to be functional, however, not self-closing or latching at the time of the visit. At this time, no residents have documented elopement or unsafe wandering behaviors. LPA advised Facility Designee to ensure the gate is self-closing and latching in the event any residents' needs change or residents are admitted that may have unsafe wandering or elopement behaviors. One (1) gate, which is utilized as the emergency exit was observed latched from the exterior during the visit. Both gates had locks nearby, but were not locked at the time of the visit. LPA advised removing the locks to ensure emergency exit pathways are clear at all times.

Garage: The garage does not have direct access to the facility and was observed locked at the time of the visit. LPA observed the garage to contain extra supplies, emergency food and water, as well as a couch, which appears to be a staff break area. There is also a locked staff room. LPA inquired with Facility Designee whether the facility had obtained permits for the staff room located in the garage, but Facility Designee was unsure. LPA was unable to reach the Fire Inspector during the visit for permit/fire clearance clarification.

Interviews: LPA conducted interviews with three (3) residents and two (2) staff. No immediate concerns were voiced during the visit.

No citations issued. Exit interview conducted and a copy of the report was provided.