The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. This is a Residential Care Facility for the Elderly (RCFE) with a fire clearance capacity of Six (6) clients. The facility has approval for (Six) 6 non-ambulatory residents, (One) 1 of which may be bedridden. The Bedridden resident must be housed in bedroom 1 or bedroom 2 of the facility. The facility has an approved hospice waiver for (Four) 4 residents.

KITCHEN: The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in a locked drawer in the kitchen. Kitchen appliances were in operable condition. The LPA observed perishable items in good condition, with proper expiration dates precluding the perishable items from expiring. The facility has a sufficient supply of perishable and non-perishable food. Additional perishable food items were maintained on a shelf and/or an extra freezer. The hot water temperature was measured in the kitchen at an appropriate temperature as per the regulation. The Kitchen area was observed by LPA to be somewhat disorganized/disheveled, but no violations of Licensing regulations were observed, and all kitchen equipment/appliances were observed to be in good/operating condition. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. The freezer and refrigerator were both in the appropriate temperate Fahrenheit. There is enough tableware and utensils for all clients living in the facility, and enough equipment for the storage, preparation, and service of food. The Kitchen are also serves as the storage area for Resident Records, Staff member records, Medication Administration Records (MARS), and the Centrally Stored Medications themselves. All these documents and medications are stored in locked and secure cabinets away from perishable food items and kitchen utensils/kitchen microwave, oven, etc. Contd. on 809-C

BACKYARD/GARAGE/ETC: The backyard area has an indoor patio area/sunroom equipped with furniture for resident use. There were no bodies of water noted. All exits from the facility are locked, which the LPA checked to make sure the locks were engaged. There is a separate laundry room where cleaning products are stored, which is kept locked. The laundry room is accessible through the garage where 2 staff rooms are also located. Cleaning supplies and disinfectants are kept in locked cabinets in the garage. There was emergency food and water in a storage room/area which was observed to be in good condition. Cleaning supplies, disinfectants, and other items that could pose a danger to clients are kept in areas inaccessible to clients. There is a first aid kit that includes sterile dressings, bandages, thermometers, scissors, tweezers, and a first aid manual. In the front of the facility, the LPA noted that the outdoor front area of the facility was observed to be clean and landscaped, with no signs of neglect or lack of maintenance.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are six (6) designated resident rooms. All the resident rooms have an individual bed for one resident. Continued on 809-C

RESTROOMS: The facility restrooms were sanitized and in operating condition while the LPA toured the facility. There are four (4) total resident restrooms, with 2 of these restrooms containing a shower/tub for the washing and bathing of residents. All restrooms inspected had assistive equipment for clients including grab bars and/or non-skid surfaces. The bathrooms were sufficiently stocked with soap, paper towels, and additional supplies; towels and washcloths are not shared. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per the regulations. Nightlights are installed in the hallways outside of the common area restrooms.

RECORDS: The facility keeps confidential storage of personnel records and resident records on-site at the facility. Personnel records reviews were reviewed for, but not limited to Personnel records, Health assessments with Tuberculosis (TB) test results, Personnel Action Notice, Job Description with date of employment, Employee Rights, Criminal record Statements, Criminal record clearances, First aid/CPR certification that is not expired, and the appropriate training documentation. All staff member personnel records had the appropriate documentation with no expiration of any training. The administrator of the facility has a pending renewal of an Active Administrator Certification with an expiration date of 12/29/2025. Resident records were reviewed for Pre-Admission/Placement appraisals, Admission Agreements, Physicians Reports, Consent Forms, Personal Rights for Residents, Emergency Information, Release of Medical Information, Needs and Services Plan (ANS), Resident Assessments, Self-management of medications if applicable, Medication Orders, and Medication Logs. All resident records reviewed by the LPA had the appropriate documentation with no missing or incomplete information.

MEDICATIONS: Medications were reviewed in the Medication Administration Record (MARS) for each resident. Medications for all residents are in a centrally stored and locked cabinet in the kitchen. The LPA observed the Licensee demonstrate the locking and unlocking of the centrally stored medication cabinet. The LPA observed and audited the medications of residents, including bubble packs, powders, and liquids. All medications are labeled appropriately according to the pharmacy and physician. There were no signs of missed medications or medication irregularities according to the LPA upon the audit of the MARS and the actual medications. Continued on 809-C

FACILITY DOCUMENTATION: The facility keeps hard copies of the Application for an RCFE, Applicant Information, Designation of Facility Responsibility, LIC 500 Personnel Report, LIC 501 Personnel Record, LIC 503 Health Screening Reports, LIC 610E Emergency Disaster Plan for Residential Care Facilities For the Elderly, LIC 9282 Infection Control Plan, Fire Safety Clearance, and Facility Sketch. The facility has a Plan of Operation, Control of Property, Staff Job Descriptions, Personnel Policy, In-Service Training for Staff, Facility Program Description, Rules of Discipline/Personal Rights, Admission Agreement for Residents, Theft & Loss Policy, Neighborhood Complaint Policy, Hazard Assessment, and Job Description for the Administrator. The facility has a Dementia Care Plan document as well as Hospice Care Waiver. The Hospice Care Waiver states the maximum number of Hospice Patients is four (4).

During this annual facility site inspection no deficiencies were cited. Technical violations were issued due to the facility previously having no medical reappraisal for injuries to a resident, no continuing record of a resident's injuries/medical care and no incident reports submitted to Licensing by facility for a resident's hospitalization on 08/11/2023 or 10/27/2023. On 10/27/2023, the licensee notified the resident's representative that the resident was hospitalized due to passing out at the dining room table. However, the licensee did not notify resident's representative of resident's 10/26/2023 fall at the facility. On 06/12/2024, LPA conducted a case management-deficiencies visit. Licensee agreed to a Plan of Correction that Licensee would submit a plan describing how facility would ensure reporting requirements were followed. Proof was submitted to LPA. LPA observed areas of the facility that appeared to be disorganized and/or cluttered. However, this was not observed by LPA to be a risk to the health and safety of residents in care. There is no widespread neglect regarding maintenance of the facility, and on-going corrective action to prevent overall deterioration of the Physical Plant is being maintained by the facility.

Exit interview conducted. A copy of the report was issued.