COMMON AREAS: This includes two (2) living rooms, and a 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 2:18 p.m., hardwire combination of smoke / carbon monoxide detectors and fire doors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 05/01/2026. 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 03/09/2026 and are conducted quarterly. Activities were observed in the common areas. At 11:12 a.m. LPA observed residents engaged in a group activity. The fireplace in the living room was adequately screened. There is a functioning telephone on the premises. 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.

INTERVIEWS: Starting at 10:09 a.m. one (1) staff and three (3) resident interviews were conducted. Staff interviews revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interviews revealed that no concerns were noted or voiced at the time of the visit. 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; All six (6) bedrooms are designated as private, single occupancy, resident rooms. There is no staff room and Administrator stated that staff remain awake at night. Five (5) of Six (6) resident rooms have exits to the exterior. All passageways were observed to be clear of obstructions. All rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen, which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair. Each bedrooms have its own supply of linens stored in the closet.

RESTROOMS: There are seven (7) total restrooms of which four (4) are designated as private en-suite resident restrooms, three (3) half-baths of which two (2) are designated for resident use and one (1) is for staff and guest use. The facility also contains a separate shower room for resident use. 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 109.2-112.5 degrees Fahrenheit, all within the required range.

KITCHEN: The LPA inspected the kitchen/food service area. 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 112.8 degrees Fahrenheit. Cleaning supplies and other chemicals are kept locked under the sink area.

GARAGE /LAUNDRY ROOM: LPA observed the locked garage /laundry room adjacent to the kitchen. Laundry room has a washer and dryer. LPA observed a sufficient supply of emergency food and water. LPA observed a staff / office area. Medications are stored in the locked cabinets inside the garage. LPA observed an extra refrigerator with food. Refrigerator was checked for proper labels and expiration dates.

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

BACKYARD: The entire property is fenced. The backyard has a covered patio area with shade, patio furniture including tables and chairs for resident use. All passageways were observed to be clear. LPA observed one (1) self-latching gate. LPA observed a swimming pool that was properly fenced and locked at the time of the visit.

Resident Records: were reviewed beginning at 11:35 a.m. four (4) 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, Home Health records, Hospice records, PRN authorization letters, and current needs and services plan. All records were in order.Personnel Records were reviewed beginning at 12:23 p.m. Six (6) 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 1:30 p.m. Medications are locked, centrally stored in cabinets located in the garage adjacent to the kitchen. Medications for four (4) residents were reviewed. Medications are labeled and checked for expiration dates. Medications reviewed were found to be self-administered as prescribed. No errors observed during review. LPA observed the first aid supplies to be complete, including sterile first aid dressings, bandages, tweezer, 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.

At the time if the visit the LPA reviewed the facilities contact information on file including phone numbers, email and annual fees. Administrator made changes to facility phone number and confirmed that all information is accurate. No citations issued at this time. Exit interview conducted. Copy of report reviewed and provided.