The LPA and Licensee Representative 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 1:25 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 12/17/2024. The emergency exiting plans/sketch are posted. 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 08/04/2025 and are conducted quarterly. Activities were observed in the common areas. The fireplace in the living room was adequately screened. 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 eight (8) total bedrooms in the facility; six (6) bedrooms are designated as private, single occupancy, resident rooms and two (2) staff rooms. The staff rooms are kept locked at all times and observed to be occupied by staff. All six (6) 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.

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.

RESTROOMS: There are three (3) total restrooms. Two (2) are designated as a shared / common resident restroom, 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 105.6-116.1 degrees Fahrenheit, all within the required range.

GARAGE: The garage is attached to the house. Washer and dryer units are located inside the garage. Emergency water and additional food is located inside the garage. Cleaning solutions, and chemicals are inaccessible and locked away in the garage. LPA observed an additional refrigerator with extra food that was checked for proper labels and expiration dates.

KITCHEN: The LPA inspected the kitchen/food service area at 10:08 a.m. Knives and sharps were observed in a locked cabinet. 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 118.6 degrees Fahrenheit at 10:09 a.m. Cleaning supplies and other chemicals are kept locked under the sink and in the garage, inaccessible to residents in care.

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. Only 1 (one) pathway is used as an emergency exit which was free of obstructions at the time of the visit.

Resident Records: were reviewed beginning at 10:15 a.m. Five (5) 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 11:01 a.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.

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

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.

INTERVIEWS: Starting at 1:20 p.m. one (1) staff and two (2) resident interviews were conducted. Staff interview 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.

MEDICATIONS: Medication review began at approximately 1:30 p.m. Medications are centrally stored and locked in a cabinet in the kitchen adjacent to the dining room. 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.

DOCUMENTS: Documents obtained during the visit include: LIC 500- facility roster, LIC 9020A -Resident roster, Updated facility sketch 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.