The facility is single story house with an attached garage. An approved fire clearance was received, clearing them for 5 non-ambulatory residents in rooms 1, 2,3,4 and 1 bedridden resident in room 5 with a total capacity of six (6). A dementia program was included in the plan of operation. A Hospice Waiver has been granted for six (6) residents.

COMMON AREAS: This includes the living room, open office area, 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 a fire door were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 04/02/2025. The emergency exiting plans/sketch are posted in every room. 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 11/19/2025 and will be conducted quarterly. Activities were observed in the common areas. 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.

The electric fireplace in the living room is non-functional, It is screened and there are no tools. 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.

BEDROOMS: There are five (5) total bedrooms in the facility; four (4) bedrooms are designated as private, single occupancy, resident rooms and one (1) is designated as a shared, double occupancy resident bedroom. There is no staff room and Designee stated that staff remain awake at night. Four (4) out of 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. LPA observed two (2) closets / storage space in the main hallway one (1) locked containing personal protection equipment (PPE) , incontinent supplies and hygiene supplies and one (1) hidden with the bamboo wall panel containing extra clean linens and towels for resident use.

RESTROOMS: There are two (2) total restrooms. One (1) is designated as a shared / common resident restroom, 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 107.4 - 108.3 degrees Fahrenheit, all within the required range.

KITCHEN: The LPA inspected the kitchen/food service area at 10:33 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 108.3 degrees Fahrenheit at 10:35 a.m. Cleaning supplies and other chemicals are kept in a locked cabinet under the sink area and in the laundry room locked and inaccessible to residents in care.

LAUNDRY ROOM: LPA observed the locked laundry room adjacent to bedroom #4 in the main hallway. Laundry room has a washer and dryer and locked cleaning supplies.

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

BACKYARD: The entire property is fenced. There are two (2) covered patio areas with tables and chairs for resident use. The back and sides of the house are separated from the front yard by gates at the north and south side passageways. There are no other structures on the property. Facility has an in-ground pool, which was observed to be fenced with an appropriate lock. Two (2) outdoor exit gates were observed to be self-closing and self-latching at the time of the visit. All passageways were observed to be clear and free of obstructions at the time of the visit.

GARAGE: LPA observed the attached facility garage, accessible through the kitchen which was locked at the time of the visit. LPA observed facility supplies such as an extra mattress, hardware supplies, a staff refrigerator, emergency food and water. LPA also observed a staff lounge area with chairs and storage space.

RECORDS: Record review began at approx. 10:40 a.m.

Resident Records: were reviewed beginning at 10:46 a.m. Three (3) 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 11:40 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.

Report Continued on LIC 809-C PAGE 4...

MEDICATIONS: Medication review began at approximately 12:11 p.m. Medications are centrally stored and locked in a cabinet in the staff dining room / open office area adjacent to the kitchen. 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 located in the laundry room.

INTERVIEWS: Starting at 1:25 p.m. and throughout the visit one (1) staff and two (2) resident interviews were conducted. Staff interview revealed that staff is 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.

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

LPA provide the facility with the updated Component III - RCFE Supplemental Handout.

No deficiencies were cited during today’s inspection. Exit interview conducted. A copy of the report reviewed and provided.