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 Four (4) Clients. The facility is approved for 4 ambulatory, developmentally disabled clients, of an age range from 18 years to 59 years old. The physical plant of the facility consists of a single story home with four (4) individual client bedrooms, a Staff room, Living room, two (2) client restrooms, Laundry room, utility room (water heater and furnace) , Kitchen, and outdoor area. The outdoor area for clients is utilized for outdoor activities/outdoor visitations with an outdoor patio area containing furniture and shade.

KITCHEN: The facility maintains one (1) main kitchen area for the Clients in care. The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are not stored in a locked drawer inaccessible to clients. The storage drawer for kitchen knives, scissors, and other sharp items that could constitute an injury to Clients was not locked. The Administrator explained that all sharp items would be locked inaccessible to Clients immediately and had not been locked because Clients in the facility often make their own meals. 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). Additional perishable food items were maintained in a storage area in a cabinet off the kitchen area of the facility in the laundry room area 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. Items that could constitute a danger to clients were kept accessible to clients in the kitchen area but moved to a locked drawer/cabinet inaccessible to clients after LPA and Administrator discussion. Continued on 809-C

COMMON AREAS: The indoor areas of the facility consist of a living room, kitchen, Staff room, four (4) client bedrooms, three (3) client restrooms, and a laundry room that also contains the locked Centralized Medication Storage cabinet which is inaccessible to clients. At the time of the visit, the common areas of the facility were observed to be appropriately furnished, with all furniture in good condition. There is a fireplace in the living room of the facility, but it is appropriately covered and inaccessible to clients. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector(s) were operational at the time of the visit. The facility has multiple fire extinguishers that were fully charged and serviced annually, all being tagged as serviced in 2023. The facility common areas also contain extra storage cabinets for additional perishable food, closets/rooms in the hallways of the facility containing extra linen/bedsheets/pillows, and storage areas for client personal hygiene equipment constituting the interior areas of the facility. The LPA observed required postings throughout the common spaces including Client Personal Rights and Contact information for Ombudsman as well as Licensing. There are activity supplies and equipment, including activity materials for the clients such as television, puzzles, games, etc. All window screens were in good repair. There is appropriate lighting in the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, and all inclines are well-lit with no stairwells/stairs for client use. The laundry area for the facility is in a room off of the kitchen of the facility that is accessible to clients, but maintains all items related to laundry locked in cabinets inaccessible to clients. There is a main entrance walkway into the facility and an administrative entrance area for visitors. The kitchen, living room, and indoor common areas are clean. Hallways, bedroom doors, and walls are in good repair.

OUTSIDE/LAUNDRY/MISCELLANEOUS: The front outdoor area of the facility is well maintained and consists of cement walkways and grass areas. The facility front yard is well maintained and is paved with a walkway up to the facility. 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 fence around the entire facility with latched gates. Continued on 809-C

BEDROOMS: The facility has four (4) client bedrooms, with three (3) being individual bedrooms for one (1) client, and one (1) being a shared bedroom for 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 a single bed or beds, nightstand, 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 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. Due to the severe rain/weather in January 2024, one of the client bedrooms experienced a leak in the ceiling from the roof of the facility. The client in care that occupied that room was immediately moved to another empty bedroom, and the Administrator informed the LPA that professional maintenance was in the process of being conducted on that bedroom. LPA observed the ceiling leak and observed evidence of the measures taken to repair the leak and provide a new bedroom for the client that had occupied that room.

RESTROOMS: There are three (3) client restrooms in the facility. The facility restrooms were sanitized and in operating condition while the LPA toured the facility. All restrooms/showers inspected had assistive equipment for clients including non-skid surfaces. Continued on 809-C

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 education, experience, training, certification for the Administrator, verification of first aid training, Criminal Record Statement, Criminal Record Clearance/Exemption, Employee Rights, and Statement Acknowledging Requirement to Report Suspected Abuse of a Dependent Adult. The administrator of the facility has an active Adult Residential Facility Administrator Certificate with an effective date of 02/18/2023, and an expiration date of 02/17/2025. All staff members’ personnel records reviewed by LPA had the appropriate documentation. Client records were reviewed for, but not limited to Preplacement Appraisal Information, Appraisal Needs and Services Plan (ANS), Physicians’ Report assessment including (Tuberculosis (TB) test results, ambulatory status, medical record, examination record, and functional changes), Identification and Emergency Information, Current Admission Agreement with authorized signatures, Record of Clients safeguarded cash resources, Record of Client personal property/valuables, Centrally Stored Medication and Destruction Record, Modification of Diet if applicable, Personal Rights forms, Consent Forms, and Restricted Health Condition Care Plan if applicable. All client records reviewed by the LPA had the appropriate documentation with no missing or incomplete information.

MEDICATIONS: The facility maintains a locked centralized storage area for client medications. Centrally Stored Medications are in a locked storage containment area within the laundry room of the facility, which is located indoors off the kitchen area of the facility. The medication cabinet area always remains locked, 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. Continued on 809-C

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 ARF License Certificate, LIC 500 Personnel Report, Plan of Operation, Emergency Disaster Plan for Adult Care Facilities, 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.

No deficiencies cited, but two (2) Technical Violations issued to the facility. Exit interview conducted. A copy of the report was issued to the facility.