LPA Sharp toured the facility along with Administrator Brown and made observations pertaining to the annual visit. LPA inspected the facility inside and outside. There were no obstructions or debris to the indoor or outdoor passageways observed. Additionally, there were no bodies of water seen on the premises at the time of this visit. The facility is a single-story building located at 320 South San Jacinto Street and no firearms observed or reported at the time of the visit.

Physical Plant: LPA Sharp observed the residents’ bedrooms, and all but one, were furnished as per Regulations and Title 22. Room 209 did not have a chair in it for people to sit in. LPA Sharp notified Administrator Brown that a chair is required. LPA Sharp inspected the facility bathrooms and observed a shared bar of soap was in the common bathroom, and no towels were visible and no paper towels were visible. The bathrooms were clean, and appliances were operating appropriately at the time of the visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA Sharp observed required postings such as "If you See Something, Say Something,” the "Personal Rights," and the LTCO poster. There were designated storage spaces for the residents’ and staff’s files, and it was locked and inaccessible to residents in care the time of the inspection.

Continue on LIC809C…

• 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.

Medications: Were locked and inaccessible to residents in care, and there was a sufficient supply of medication for each resident. Medications were stored in their original containers at the time of the inspection. LPA performed an audit of the medication and observed the visible MARS were dated 7/31/2026, the day of the visit it was 8/5/2026. This would be in contrast to the passing of medication daily. Resident 1 (R1) had medication that was dispersed through 8/6/2026 already.

Food Service& furniture: The perishable food supply was sufficient per regulations, but the non-perishable were a little scarce. Administrator Brown notified LPA Sharp that food is delivered on Fridays after 6:00 p.m. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked. The overall facility is clean; the furniture is in good condition and arranged in a manner which provides space for residents to move safely. There are several cabinets in the resident’s rooms, kitchen and restrooms that are in need of repair (i.e., difficult to open or difficult to close).The facility cooling system and other appliances were operable at the time of the visit, and temperatures registered within regulation.

Records Reviewed and Resident/Staff Files: LPA Sharp reviewed the staff files and the facility's staff schedule. The staff files reviewed had criminal clearances, updated training's, along with current First Aid certifications, but the reviewed staff were missing personal rights. The resident files reviewed did not possess the required paperwork as per Regulations at the time of the visit. They were from another facility and not showing updated for the current facility.

Infection Control: LPA requested a copy of the infection control, but Administrator could not produce one. Due to time, LPA will have to finish the annual later and issue the necessary deficiencies at that time.

An exit interview was conducted. A copy of this report, and an 811 was submitted to the Administrator, Prescilla Brown