Beginning at 01:52 PM, the LPA, along with the Administrator 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:

OUTDOOR SPACE: The facility has one (1) emergency exit gate located on the side of the facility. LPA observed clear passageways for emergency exit use. The facility had adequate shaded seating for resident use. Cameras were observed on the outdoors of the facility. All window screens appeared to be in good repair. LPA observed a sunroom attached to the outdoors of the facility which contained adequate shaded seating for resident use.

COMMON AREAS: This included the living room, hallway, dining area, and Administrator’s office. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room was observed to contain a television and activities for resident use. Additionally, the living room contained an appropriately screened fireplace. The hallway was observed to be clean and free from any obstructions. The hallway contained two (2) closets which contained extra linens. The dining area was observed to be clean and contained adequate seating for residents’ use. The Administrator’s office was observed to be inaccessible to clients in care. The Administrator’s office contained locked storage for resident medications and facility files. All furniture in the facility was observed to be clean and in good repair. Smoke detectors and carbon monoxide detectors, along with the facility’s fire door, at 02:09 PM and were functional at the time of the visit. CONTINUED ON LIC 809C.

BEDROOMS: There are three (3) bedrooms in the facility; all are designated as dual occupancy rooms and all are designated for resident use. LPA and the Administrator toured all three (3) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Bedroom #3 contained a direct exit to the outdoors of the facility and is the bedridden approved room.

BATHROOMS: There are two (2) bathrooms at the facility. One (1) is designated as a resident bathroom and one (1) is designated as a staff bathroom. Both bathrooms were observed to be clean and in good repair and all were equipped with nonskid surfaces. Grab bars were observed in the resident shower and near the resident toilet. All grab bars were properly secured. The water temperature was measured to be 108.5 degrees Fahrenheit, which is in compliance with regulation.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. The facility’s emergency disaster plan is up to date and is adequate. The last emergency disaster drill was conducted on 06/29/2026. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator.

During today’s visit LPA obtained a copy of the facility’s updated emergency disaster plan, LIC 500, resident roster, and liability insurance. Due to time constraints LPA will return at a later date to conduct staff and resident file reviews, staff and resident interviews, and a medication review.

Exit interview conducted. And a copy of the report was provided.

• 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.