LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has an updated Infection Control Plan. Staff are adhering to infection control requirements.

Operational Requirements: Hospice Waiver for 30 is approved. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires on 02/01/2026. Surety bond in the amount of $10,000 is current.

Physical Plant/Environment Safety: The facility is a single story building which consist of reception area, large dining area, forty nine (49) resident bedrooms, administration office, business office, medication room, kitchen, storage room, cooler, electrical room, conference room, janitor's room, salon and outdoor seating/smoking areas. The interior and exterior physical plant was inspected. Kitchen was inspected, knives, cleaning solutions, and disinfectants are locked and inaccessible to residents. LPA toured random resident rooms which were newly painted and observed each bedroom to contain the required furniture and linens. Bathrooms were observed to be clean. The signal system was tested in various locations and is operable. The fire extinguishers were observed to be fully charged and in compliance. Exit doors are free of any obstruction and there are no pools or large bodies of water. There are no security bars or weapons on the premises. Cleaning supplies and toxic substances are inaccessible to residents. LPA tested hot water temperature in eight (8) random rooms (#4, #6, #17, #18, #37, #39, #40, #42) and the readings vary between 84 deg F to 123 deg F which did not meet the required 105 - 120 deg F stated in Title 22 regulations. *****CONTINUED ON LIC809-C****

• 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.

Personnel Records/Staff Training: LPA reviewed (5) staff files and confirmed health screenings and fingerprint clearances. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator and Assistant Administrator's applications were submitted for renewal and currently pending.

Resident Rights-Information: Resident personal rights are posted. Notice of visiting policy is posted. Facility provides internet services to all residents and have access to the facility phone.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Facility does not have a designated staff member to organize, conduct and evaluate planned activities for residents. Additionally, there is no written calendar of activities provided to the residents. The facility has a Resident Council, but currently no active members involved. Facility provides equipment and space to accommodate both outdoor and indoor activities.

Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed.

Incidental Medical and Dental: Residents medications were reviewed containing 30-day supply of medications. Medications are centrally stored, properly labeled and are in bubble packs. First aid kits are kept in the facility but are not easily accessible.

Resident Records/Incident Reports: Resident files are maintained at the facility. A total of (5) resident files were reviewed. They contained Admission Agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, Medical Consent, Medication Records, and P & I money records.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place.

Residents with Special Health Needs: Currently, (6) residents receive hospice care, of which (1) is being administered oxygen and (2) are bedridden. Half bed rails for mobility assistance were observed in some resident beds. Functional Capability and Preplacement Appraisals are on file.

Deficiency issued on LIC809-D and Technical violations were issued. An exit interview was conducted, and a copy of this report was provided to Maria Luisa Razo, Assistant Administrator along with the Appeals Rights.