LPAs, along with Administrator, toured the facility beginning at 01:54PM to ensure client health and safety and the facility is in compliance with Title 22 regulations. The following was observed:

Hardwired combination smoke and carbon monoxide detectors were tested at 02:32PM and were functional at the time of the visit. Fire extinguishers were observed throughout the common areas, and were fully charged and last serviced 11/15/2023.

COMMON AREAS: The facility is a 2-story home, consisting of an upstairs and a downstairs area. There are no common areas upstairs. Downstairs common areas include a living room, study, and dining area. All furniture appeared clean and in good condition. A dual-sided fireplace in the study/dining room, and separate fireplace were observed in the living room and an additional fireplace in the upstairs office; all fireplaces were observed to be adequately screened at the time of the visit.

TREATMENT/THERAPY, MEDICATION ROOM & OFFICE AREAS: Upstairs rooms were observed to remain locked at all times, and accessible to clients when they are with staff. Upstairs consists of 2 office areas and a group therapy room. Downstairs contains a locked nurse/staff office, which contained a locked medication closet. At 03:38PM, medications were reviewed for 2 (two) clients. Medications observed were properly labeled and medication records observed were documented per regulation. The First Aid Kit is stored in the Medication Room and was observed to be complete. The Offices are kept inaccessible to clients unless properly supervised.

KITCHEN: Appliances and fixtures appeared clean and functional. There was sufficient nonperishable food Report Continued on LIC 809-C

LAUNDRY/GARAGE: Locked Laundry Room is located on the ground floor. Laundry supplies were observed inside the locked laundry room. The locked garage was observed to contain locked chemical storage, emergency food and water, as well as activity and other supplies.

BEDROOMS: There are three (3) bedrooms, all of which are designated for shared client use. All bedrooms are located on the first floor and were observed to contain appropriate furniture, bedding and linens. There were no visible hazards observed.

BATHROOMS: There are four (4) Bathrooms, three (3) on the ground floor and one (1) on the second floor. The bathrooms located on the ground floor include a shared full bathroom, a private full bathroom designated for client use and a half bath in the hallway for staff use. The bathroom located on the second floor is a full bathroom designated for staff use. All bathrooms were supplied with appropriate paper and hygiene products. Water temperature in all client restrooms initially measured high, however water temperature was adjusted during today's visit and subsequently consistently measured within the required range.

SURROUNDING GROUNDS: The Front Yard includes a driveway, paved walkways and landscaped areas. The backyard is fenced and includes both paved and landscaped areas, a patio, furniture appropriate for outdoor use, an in-ground swimming pool and separate in-ground hot tub. The pool is kept inaccessible to clients with the use of fencing that includes a locked gate. The hot tub contains a locked cover. Staff have received the appropriate Water Safety Certification and Administrator stated that qualified staff are present at all times that the pool or hot tub is in use by clients. No immediate hazards were observed during the visit.

STAFF/CLIENT FILE REVIEW/INTERVIEWS: LPA reviewed 5 (five) staff records during today's visit. LPA reviewed 5 (five) client file records during the visit. All staff and client records reviewed were in compliance with Title 22 regulation at the time of the visit. During today's visit, LPAs interviewed 3 (three) clients and 4 (four) staff.

INFECTION CONTROL/DISASTER PREPAREDNESS: During today’s visit, the LPAs reviewed the facility's infection control policy and disaster preparedness policies. All items reviewed were in compliance.

Exit interview conducted. Today’s report was reviewed and provided.