• 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.

GARAGE: The garage is detached to the house. Garage was observed to be locked. Garage is used as storage of decoration, furniture and extra supplies.

CLIENT RECORDS: were reviewed beginning at 11:18 a.m. Four (4) client 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 client files reviewed were complete and contained all documentation required. LPA observed that two (2) clients currently residing in the facility are over the age of 60. LPA advised the administrator to submit an age exception request to Community Care Licensing (CCL), documenting that the Adult Residential Facility (ARF) is the most appropriate setting to meet the needs of these individuals and sent an email with the required elements that need to be submitted. Technical violation Issued as this was discussed during last years annual inspection. PERSONNEL RECORDS: were reviewed beginning at 12:30 p.m. two (2) 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. Documents updated as of 01/08/2026.

BACKYARD: The entire property is fenced. The backyard has a patio area with shade, patio furniture including a table and chairs for client use. All passageways were observed to be clear. There were no bodies of water noted at the time of the visit. LPA observed two (2) self latching gates. Emergency exits were free of obstructions at the time of the visit. LPA observed a side gate to be self-latching and closing with clear passageways for emergency exit use. LPA observed a detached studio on the premises. The studio was secured with a keypad lock. Upon entry, LPA observed that the space was being used as the administrator’s office and for storage of extra supplies.

P&I MONEY: The Facility does handle cash resources for three (3) clients. Surety Bond is current. At 1:04 p.m. the LPA and Administrator reviewed Two (2) of three (3) clients who have their cash resources safe guarded by the facility. Cash resources were found to be separate and intact and not commingled with facility funds or petty cash. All records were in order.

MEDICATIONS: Medication review began at approximately 1:15 p.m. Medications are centrally stored and locked in a cabinet in the living room adjacent to the dining room. Medications for three (3) clients were reviewed. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to clients 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.

At the time if the visit the LPA reviewed the facilities contact information on file including phone numbers, email and annual fees. Administrator updated email and confirmed that all information is accurate.

No citations issued. Exit interview conducted. Copy of report reviewed and provided.