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 an Adult Residential Facility (ARF), with an approved fire clearance capacity of or six (6) developmentally disabled clients, four (4) non-ambulatory and two (2) ambulatory. The facility fire clearance approves non-ambulatory clients in bedrooms #1 and #2 only. The physical plant of the facility contains three (3) client bedrooms, three (3) client restrooms (2 with toilet and bathtub/shower and 1 with only toilet), kitchen, dining room, living room, and laundry room/garage. There is an outside area of the facility that contains a large, covered gazebo for clients to utilize for outdoor activities with furniture and shade.

The LPA inspected the food service area in the facility and observed that items which could constitute a danger to clients are kept inaccessible to clients. All appliances were in operable condition and looked clean/in good repair. Appliances such as microwaves, refrigerators, stoves, etc. are clean and operating properly. Food utensils, dishes, glasses, etc. are clean and in good repair with no cracks or chips. There is enough tableware and utensils for all clients living in the facility, and enough equipment for the storage, preparation, and service of food. LPA observed an appropriate/adequate amount of perishable and non-perishable food items maintained in the facility. Furniture is room/client appropriate, clean and in good repair. All rooms are appropriately furnished for their intended use such as bedrooms, common areas, etc. Hot water temperature is maintained between 105-120 degrees Fahrenheit as per Community Care Licensing (CCL) Title 22 regulations. Outdoor activity spaces have shaded areas and furnished for outdoor use. Each client has an adult bed with a mattress, pad, bedsprings, and pillow, which are clean and in good repair. Each bed is fitted with sheets, pillowcase, blankets, and bedspread that are clean and in good repair. Continued on 809-C

At the time of the visit, the common areas of the facility were observed to be appropriately furnished, with all furniture in good condition. This is a two-story family home, with the facility maintained on the first story of the building only. Clients are not allowed on the second floor of the facility. The facility interior consists of a lounge room area, playroom area/dining room, kitchen, client bedrooms, client bathrooms, a staff bedroom, multiple closets/storage areas, a laundry room, and a garage/storage area. The facility maintains a locked centrally stored medication containment area off the dining room area for clients. There is one fireplace in the facility that is covered and inaccessible to clients. The LPA observed required postings throughout the common spaces of the facility. There are activity supplies and equipment, including activity materials for the clients. The facility maintained a comfortable temperature in all areas inspected. LPA did not observe any noticeable outdoor hazards. Outdoor activity spaces in the facility are shaded and equipped with furniture for client use. The facility has adequate storage of additional supplies/emergency supplies. Designated laundry area in the facility has appropriate storage of cleaning products, which are kept locked/inaccessible to clients. Continued on 809-C

An emergency exiting plan and emergency phone numbers are posted in an appropriate place. First-aid supplies, which include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual, are maintained. Administrator’s records, employees and client records are maintained at the facility and available for review by the LPA as employees are hired and clients accepted into the facility. The facility complies with CCL standards for health screening, TB clearance, staff training, criminal background clearance and transfer requests. Admission agreements and needs and services (ANS) plan are maintained for each client and/or their authorized representative. Client records are maintained on the facility premises in a secured area. Centrally stored medications are locked inaccessible to clients. The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record. The facility administrator meets the qualifications as specified in Title 22 regulations with an active ARF administrator certificate that expires on 07/04/2026. The administrator’s husband also has an active ARF administrator certificate that expires on 04/07/2026. Provider Information Notices are available and able to be presented to Staff, clients, visitors, and accessible to LPA upon request during the inspection process. Facility emergency disaster plan/evacuation procedures has two evacuation locations listed, but both are in the same general area as the facility. LPA notified facility that one evacuation location needs to be outside the immediate area of the facility location. Exit interview conducted by LPA. Copy of this report provided to the facility.