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 double-story home located in a residential neighborhood.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 1:09 p.m., hardwire combination of smoke / carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 07/18/2025. The emergency exiting plans/sketch are posted in every room. 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 04/20/2026 and are conducted quarterly. Activities were observed in the common areas. The fireplace 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. LPA observed surveillance cameras installed in the common areas of the facility. The Administrator presented the live monitoring screen to the LPA, confirming that all cameras were functioning properly and that none of them were equipped with audio capability.

INTERVIEWS: Starting at 10:52 and throughout the visit LPA conducted two (2) staff and three (3) resident interviews. Staff interviews revealed that staff are 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. Report Continued on LIC 809-C PAGE 2...

• 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.

BEDROOMS: There are nine (9) total bedrooms in the facility; four (4) bedrooms are designated resident rooms of which two (2) are shared, double occupancy and two (2) are private, single occupancy, resident rooms and five (5) staff rooms. The staff rooms are 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 six (6) total restrooms. Two (2) are designated as a shared / common resident restrooms. Resident restrooms were observed to be equipped with a slip resistant surface / mat. Grab bars were observed in the restrooms. The restrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in all resident restrooms and ranged between 119.1-120 degrees Fahrenheit, all within the required range. LPA advised the Administrator of the regulatory standard of 105-120 degrees Fahrenheit, as the water temperature was at the maximum. LPA observed storage space closets in the hallway containing extra clean linens and towels for resident use.

KITCHEN: The LPA inspected the kitchen/food service area. 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. Cleaning supplies and other chemicals are kept under the sink locked and inaccessible to residents in care.

BACKYARD: The entire property is fenced. The backyard has a covered patio area with shade, patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed one (1) self-latching gate. There were no bodies of water noted at the time of the visit. There is a small locked storage shed in the back yard inaccessible to residents. Only one (1) pathway is used as an emergency exit which was free of obstructions at the time of the visit. Report Continued on LIC 809-C PAGE 3...