The facility's fire clearance is approved to serve six (6) non-ambulatory residents, ages 60 and older, of which one (1) resident may be bedridden in Bedroom #3. The facility also has an approved hospice waiver for six (6) residents.

At the time of the inspection, there were no residents residing at the facility and no staff providing care or supervision. The Administrator was present during the inspection and assisted LPA with the annual inspection.

Facility Tour & Observations:

Personal Rights postings (LIC 613C and Ombudsman), Complaint Poster (PUB 475), and nondiscrimination notice were observed in a common area. Residents had access to personal space, privacy, and adequate storage. No firearms/weapons were present.

Physical Plant

Here is a revised version with the grammar corrected and the observations stated more clearly for the annual report:

Physical Plant and Environmental Safety:

The facility is located in a residential neighborhood and is a single-story home consisting of five (5) resident bedrooms, one (1) caregiver corridor, three (3) bathrooms, one (1) of which is a private resident bathroom, a living room, family room/sunroom, kitchen/dining area, attached garage w/washer and dryer, front yard, and backyard. All resident bedrooms observed contained the required furnishings, including beds, mattresses, linens, dressers, chairs, and adequate lighting. LPA observed designated areas for the storage of sharps, cleaning supplies, and other potentially hazardous items under lock and inaccessible to residents. Due to the facility currently being unoccupied, LPA observed that the facility was in need of general cleaning. Dust and residue were observed throughout various areas of the home, including the resident bedrooms, bathrooms, and common areas. The Administrator was informed of the observed conditions and the need to ensure the facility is thoroughly cleaned and maintained prior to residents returning to the facility. (continued on 809C)

• 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.

Food Service:

The refrigerator and freezer were observed to be operational and maintained at appropriate temperatures. No food was stocked or stored at the facility, as there are currently no residents residing at the facility and no staff providing services.

Health-Related Services and Resident Records:

There were no resident records or medications available for review, as there are currently no residents residing at the facility.

Disaster Preparedness:

The LIC 610D Emergency Disaster Plan was available for review. Emergency supplies, including water, food, flashlights, batteries, and first-aid supplies, were observed and available at the facility.

Personnel Records and Training:

There were no staff records available for review, as there are currently no staff working at the facility. Administrator Teresita Maralit's Administrator Certification was reviewed and found to be current and valid.

An exit interview was conducted with Teresita Maralit, Administrator . During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. A copy of this report, LIC 809D/809C, and appeal rights will be provided.