The LPA and Administrator 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. The facility is a single-story home located in a residential neighborhood. At the time of the visit three (3) residents were at day program and one (1) resident was observed at the facility.

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 12:25 p.m., hardwire combination of smoke and carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguisher was observed and purchased on 03/26/2026. 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 02/26/2026 and are conducted quarterly. Administrator stated they have the next one scheduled this month. They had a fire dill on 03/26/2026. Activities were observed in the common areas. During the visit LPA observed resident engaged with staff in the living room doing arts and crafts. The fireplace / chimney 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.

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• 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.

LPA observed a surveillance camera installed at the exterior / entrance of the facility. The Administrator presented the live monitoring screen to the LPA, confirming that the camera was functioning properly and was not equipped with audio capability.

INTERVIEWS: Starting at 9:32 a.m. one (1) staff and one (1) resident interviews were conducted. Staff interview revealed that staff is knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interview revealed that no concerns were noted or voiced at the time of the visit.

KITCHEN: The LPA inspected the kitchen/food service area at 9:50 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 111.6 degrees Fahrenheit. Cleaning supplies and other chemicals are kept in the garage locked and inaccessible to residents in care. LPA observed an open office area with a desk in the kitchen area no hazards observed.

BEDROOMS: There are four (4) total bedrooms in the facility; three (3) bedrooms are designated as resident rooms of which two (2) are private, single occupancy, resident rooms and one (1) is a shared double occupancy, shared, resident room, and one (1) staff room. The staff room kept locked at all times and observed to be occupied by staff. All passageways were observed to be clear of obstructions. All rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen, which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair. Each bedrooms have its own supply of linens stored in the closet.

RESTROOMS: There are two (2) total restrooms. One (1) is designated as a shared / common resident restroom, and one (1) is designated as a staff restroom. Resident restroom was observed to be equipped with a slip resistant surface / mat. Report Continued on LIC 809-C PAGE 3...

Grab bars were observed in the restroom. The restroom was sufficiently stocked with supplies and paper towels. The hot water temperature was measured in the resident restroom and measured at 111.1 degrees Fahrenheit, within the required range. LPA observed storage space closets in the hallway containing extra clean linens and towels for resident use.

LAUNDRY ROOM: LPA observed an open laundry area adjacent to the kitchen. Laundry area has a washer and dryer and a locked cabinet with tools directly above the machines. Detergent is kept locked in the garage.

GARAGE: LPA observed the attached facility garage, adjacent to the kitchen and laundry area. The garage was locked at the time of the visit. LPA observed emergency food, water, personal protection equipment (PPE) and incontinent supplies.

OUTDOOR SPACE: LPA observed a shaded area with a table and chairs for resident use in the front porch area. LPA observed chairs in the back porch area for resident use. There were no bodies of water noted at the time of the visit. LPA observed an additional dwelling unit (ADU) behind the property separated by a gate / fence. No obstructions, All passageways were observed to be clear.

RECORDS: Resident Records were reviewed beginning at 10:25 a.m. four (4) 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, PRN authorization letters, and current needs and services plan. Personnel Records were reviewed beginning at 11:45 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. The emergency disaster plan was last updated and reviewed on 05/07/2026.

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

MEDICATIONS: Medication review began at approximately 1:15 p.m. Medications are centrally stored and locked in a closet adjacent to the entrance. Medications for two (2) residents were reviewed. Medications are labeled and checked for expiration dates. All medications including PRNs were properly documented on the centrally stored medications and destruction record, stored, locked and inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed. No errors observed during review. LPA observed the first aid supplies to be complete, including sterile first aid dressings, bandages, tweezer, a thermometer and a current version of a first aid manual.

P&I MONEY: At 1:30 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.

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

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