The LPA along with staff toured the physical plant areas inside and outside from approximately 12pm-12:30pm, to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

COMMON AREAS: 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 receipt attached (3/2026). 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 observed.

BEDROOMS: There are six (6) bedrooms for resident use and one (1) staff bedroom. All bedrooms are designated as private rooms. All resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting.

• 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.

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.

KITCHEN: 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. The hot water temperature was measured in the kitchen sink, and it measured at 113.9 degrees Fahrenheit.

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. No obstructions or hazards observed.

RECORDS: LPA reviewed Resident Records and Staff Records starting at 1p.m. Six (6) 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. Three (3) resident hospice records also reviewed. 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. Administrator’s Certificate is valid till 11/17/2026.

During today’s visit, the LPA interviewed three (3) residents and two (2) staff. No concerns were noted

Report Continued from LIC 809C...

MEDICATIONS: Medications review began at approximately 3:30 p.m. LPA reviewed three (3) resident medications and records. 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 and records matched accordingly; medications appeared to be given as prescribed during the visit.

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