Beginning at 10:06AM, the LPA, along with staff, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN/LAUNDRY: Kitchen appliances appeared clean and were in operable condition at time of visit. Facility had a sufficient supply of perishable and nonperishable food. Food labels were inspected and checked for expiration dates. Knives and sharps were stored locked in staff bathroom by kitchen. Cleaning supplies, washer and dryer, and detergents were located in the locked laundry room adjacent to the kitchen.

BEDROOMS: There are five (5) total bedrooms in the facility; four (4) are designated as private resident rooms and one (1) is a shared resident room. Bedrooms #1, #3, #4, and #5 have direct exits to the exterior. LPA observed resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. LPA observed four (4) out of five (5) bedrooms equipped with surveillance cameras that do not record audio. Administrator indicated that the cameras were installed with resident/responsible party(ies)’ consent.

Report Continued on LIC809-C.

• 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.

COMMON AREAS: This includes the living room, dining room, den, and sitting room areas. LPA observed common areas to be clean and properly furnished at the time of the visit. LPA observed surveillance cameras in common rooms which do not record audio. Fireplace in the living room was adequately screened. The facility smoke alarm system is hard wired; the combination smoke and carbon monoxide detectors were tested and operable at the time of the visit. The fire extinguishers were fully charged and last serviced 05/21/2026. LPA observed required postings upon entry.

OUTDOOR SPACE/GARAGE: The backyard has covered patio areas with patio furniture including tables and chairs for resident use. All passageways were clear and free of obstruction. There were no bodies of water on the premises. LPA observed a guest house in the backyard where Licensee/Administrator lives. LPA observed the front gate to be unlocked and self-latching, as is required. The detached locked garage is used as the facility office.

MEDICATION REVIEW: At 10:45AM, LPA reviewed medications for two (2) residents. Medications were centrally stored and locked in the staff bathroom by the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents. Medications were properly documented and logged. No errors observed during the medication review.

RECORD REVIEW: Beginning at 11:12AM, LPA reviewed six (6) out of six (6) resident files and four (4) personnel files for documents including but not limited to: medical records, care plans, resident Admission Agreement, TB test, health screening, staff training, first aid certification, and fingerprint clearance. All resident and personnel files were in order.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control policy and emergency disaster plan. Emergency disaster plan is updated annually as required and emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 05/05/2026. All documents reviewed were updated and in compliance.

No citations were issued at this time. Exit interview conducted. A copy of the report was issued.