All resident bathrooms were observed. Hot water temperatures were measured in between 107.6 – 109.9 degrees Fahrenheit. No hazardous items were observed in the resident bathrooms.

The kitchen was clean and organized. LPA observed a perishable and nonperishable food supply in compliance with regulation guidelines. Knives and sharp objects are kept locked in a drawer near the stove. The stove was operation and all burners, and the warmer were operational. There’s a locked filing cabinet in the kitchen with resident medications and below the locked medications is a supply of nonperishable food items. A fire extinguisher was observed fully charged and mounted on the wall behind the dining table.

A Carbon monoxide detector was observed mounted on the wall near the stairs and tested operational.

There’s a locked office area, a staff bedroom, and a bathroom on the second level of the facility. The second level of the facility is off limits and inaccessible to residents in care. Staff and client files are locked in the office.

Continued on LIC809C

The backyard was clean and organized. Walkways are free of obstruction. During the tour of the exterior portion of the facility, LPA Haley observed a shaded patio area with a table and chairs. The side exit gate is self-latching.

Smoke detectors were observed in all resident rooms, the living room, and hallways. During the inspection all smoke detectors tested operational.

The last emergency drill was conducted November 18, 2024, and are conducted quarterly for staff on each shift.

During the inspection, 3 resident files were reviewed, 3 resident medications were reviewed, 2 staff files were reviewed, and 2 staff members were interviewed.

Deficiencies are being cited for observations made during the inspection, record review, and a Technical Advisory will be issued.

An exit interview conducted, and a copy of this report was provided to Licensee/AD Mark Fisk