LPA and administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 10 bed facility with a current census of 9. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. Chemicals and medications noted to be locked to residents in care. LPA also conducted the care tool. No bodies of water were observed at the facility.

Hot water temperature was measured at 115 F degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. All necessary documents were in place. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils.

The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point.

LPA observed, fire extinguishers inspected on 10/15/2024 and current, smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance.

LPA reviewed two (2) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required. Staff S1 and S2 did not have valid CPR training in there file administrator called and staff took CPR training before LPA left the facility. Proof of completed training's will be emailed to LPA Lewis by COB 1/15/2025.