Starting at 10:09 a.m., the LPA along with the 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 following was observed:

KITCHEN: The LPA inspected the kitchen/food service area at 10:26 a.m. Knives and sharps were observed locked and inaccessible in a kitchen drawer. Cleaning supplies were observed under the kitchen sink inaccessible to residents in care. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. At 10:30 a.m., the hot water temperature was measured in the kitchen sink, and it measured at 113.9 degrees Fahrenheit.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The LPA observed the fire extinguisher to be fully charged with a date of 02/08/2025. Required postings were observed throughout the common space. Activities were observed in the common areas. There is a working telephone on premises. Cameras observed in the common areas. The LPA observed a closet in the hallway with additional clean linens and towels. Auditory alarms were observed at the time of the visit. No obstructions or hazards were observed inside or out.

Report Continued on LIC 809C...

BEDROOMS: There are six (6) bedrooms for resident use. All bedrooms are designated as private rooms. All resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPA observed a staff bedroom on premises.

GARAGE: The garage was locked and inaccessible to residents at the time of the visit. The LPA observed an adequate amount of emergency food and water. Washer and dryer were observed inside the garage. Additional cleaning supplies are kept in the garage locked and inaccessible to residents in care.

BACKYARD: The backyard has a covered patio area with patio furniture for resident use. All passageways were observed to be clear of any obstructions. There are two (2) side gates with latching mechanisms. No bodies of water noted at the time of the visit.

RECORDS: The LPA reviewed Resident Records and Staff Records starting at 10:46 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, and current needs and services plan. All files were in order.

Three (3) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All records were in order.

Report Continued on LIC 809C...

During today’s visit, the LPA interviewed one (1) resident. No concerns were noted.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. The LPA also reviewed the facility's emergency and disaster plan, which was observed to be complete and recently reviewed/updated. Emergency disaster drills conducted quarterly as per regulation; the last one being a fire drill which was conducted on 03/05/2025.

MEDICATIONS: Medications review began at approximately 12:40 p.m. Medications are centrally stored and kept in a locked closet by the main entrance. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRN authorization letters were observed in each resident’s file. Medications appeared to be given as prescribed at the time of the visit.

No citations issued. Exit interview conducted. A copy of the report was issued.