The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. This is an Adult Residential Facility (ARF), with an approved fire clearance capacity of Ten (10) clients. The facility is approved for 10 ambulatory clients, with an age range of 18 years old to 59 years old. The physical plant of the facility consists of a living room, dining room, Staff office room, kitchen, Five (5) client bedrooms, Four (4) client restrooms, a garage area, and patio. The facility contains an outside area for clients to utilize for outdoor activities/outdoor visitations and an outdoor patio area with furniture and shade.

KITCHEN: The facility maintains a kitchen room/area within the interior of the facility. The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in a locked drawer inaccessible to clients. Kitchen appliances were in operable condition and looked clean/in good repair. 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, which would last over a week (7 days) in both the kitchen and the storage area located in the garage of the facility. The hot water temperature was measured in the kitchen at an appropriate temperature as per the regulation between 105-120 degrees Fahrenheit. The kitchen was clean and sanitary, with covered trashcans and operating ventilation systems. 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 the appropriate temperate Fahrenheit for the storage of food and prevention of spoiling. There is enough tableware and utensils for all clients living in the facility, and enough equipment for the storage, preparation, and service of food. Continued on 809-C

OUTSIDE/LAUNDRY/MISCELLANEOUS: The front outdoor area of the facility consists of cement walkways and grass areas along with a parking lot in front of the main entrance to the facility. The facility outdoor areas are maintained with no observable hazards to clients in care. The backyard/patio room is conducive for outdoor visitation. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. The exterior of the facility has a closed perimeter which consists of a wall around the entire facility with additional wooden fence posts. Inside of the perimeter is the outdoor/outside activity area for clients with a patio in the backyard, furniture, and shade. There are no bodies of water noted on the facility property. The designated laundry area is located in the garage of the facility next to a Staff only locked room/garage of the facility, which is where cleaning products are stored, which are kept locked and inaccessible to clients. Clients are allowed to do laundry, but any hazardous/toxic laundry material is kept locked at all times. There was emergency food and water in a storage area in the back of the facility and in the extra perishable food storage 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. Contd. on 809-C

BEDROOMS: The facility consists of five (5) bedrooms, with all bedrooms being shared between two (2) clients. The LPA observed the client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. The bedrooms have storage areas for clean linens, towels, pillows, etc. Each client’s bedroom has two single beds, nightstands, and lights/nightstand lamps to provide sufficient lighting. Each closet in all the client rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any client. The client bedrooms are big enough for all the beds, furniture, and any client assistive device a client might need such as a wheelchair or a walker. Each room has sufficient lighting for each client.

RESTROOMS: There are Four (4) client restrooms in the facility. Facility restrooms were sanitized and in operating condition while the LPA toured the facility. All restrooms/showers inspected had assistive equipment for clients including grab bars and/or non-skid surfaces. The restrooms 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 between 105-120 degrees Fahrenheit. Nightlights are installed in the hallways outside of the client restrooms. All client restrooms consist of a sink and toilet, while the client shower/bathing areas consist of a shower and/or bathing area with grab bars and non-skid surfaces.

RECORDS: The facility keeps confidential storage of both client and Staff member records on-site at the facility. Staff member records were reviewed for, but not limited to Health Screening Report/Tuberculosis (TB) Clearance for facility personnel, Personnel Record (employment application), verification of age over 18 years old, education, and experience, approved Certification for the Administrator, verification of first aid training, Criminal Record Statement, Criminal Record Clearance/Exemption, Verification of Staff training, Employee Rights, and Abuse Reporting Requirements. All staff members’ personnel records reviewed by LPA had the appropriate documentation. The administrator of the facility has an active Adult Residential Facility (ARF) Administrator Certificate. Continued on 809-C

MEDICATIONS: The facility maintains a locked centralized storage area for client medications. Centrally Stored Medications are in a locked storage containment area in the facility. The medications remain locked at all times, inaccessible/locked to clients. The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record, The Medication Administration Record, and the record of Controlled Medications. LPA audited the medications for clients and noticed no irregularities or issues concerning the dispensing of medications or the logging of medications. The medications in the facility were labeled appropriately with no additional or prohibited markings by the facility.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening and a sanitation station. The staff members will keep up signs that promote good hand hygiene and symptoms of COVID. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

FACILITY DOCUMENTATION: There are required postings throughout the facility, including emergency exit plans with necessary telephone numbers. The facility keeps posted copies of facility documentation such as the License Certificate, Personnel Report, Plan of Operation, Emergency Disaster Plan for Adult Residential Facilities (ARF), Facility Infection Control Plan/Mitigation Plan, Certificate of Liability Insurance, Valid Administrator Certificate, and a Facility Sketch. Provider Information Notices are available and able to be presented to Staff, clients, visitors, and accessible to LPA upon request during the inspection process.

LPA noted that no violations, technical assistance, or citations were issued during this annual inspection at this time.

No deficiencies cited. Exit interview conducted. A copy of the report was issued to the facility.