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 an approved fire clearance capacity of six (6) non-ambulatory residents. This facility has an approved hospice care waiver for four (4) residents in care. The Licensee has an approved waiver to operate the facility an include persons with dementia who are also non-ambulatory.

INDOOR COMMON AREAS: The indoor area of the facility consists of a living and dining room area, kitchen area, resident bedrooms, restrooms, storage areas, and staff office. At the time of the visit, all 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, which is covered and inaccessible to residents in care. The facility maintained a comfortable temperature. LPA observed that carbon monoxide/smoke detectors were operational at the time of the visit. The fire extinguisher was fully charged and serviced annually. The LPA observed required postings throughout the common spaces including Resident Personal Rights and Contact information for Ombudsman as well as Licensing Department. There are activity supplies and equipment, including reading materials for the residents. 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/changes in height in the interior of the facility are well-lit for resident safety. As the facility has a capacity of six (6) residents total, there is no signal system. There is adequate space available for storage of residents' personal belongings. Disinfectants, cleaning solutions, poisons, and items which could pose a danger to residents are stored inaccessible to residents. The facility was observed by the LPA to be clean, safe, sanitary and in good repair for the safety and well-being of residents, staff, and visitors. Continued on 809-C

OUTSIDE/LAUNDRY/MISCELLANEOUS: The facility has a covered patio in the backyard area as observed by the LPA. The front outdoor area of the facility consists of a lawn in the front of the facility, and an outdoor driveway with space to park two (2) vehicles. There is also a garden in the front of the facility and the back of the facility, separated by a wall with resident bench. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. Outdoor activity spaces are completely enclosed by a fence and gates. Outdoor activity spaces in the backyard are equipped with furniture for resident use including a patio with an umbrella for shade. All outdoor areas are well-lit, and the facility maintains an outdoor surveillance system. There were no bodies of water noted. There is a designated laundry area with a washer and dryer, with cleaning products stored across the hallway, which are kept locked. The laundry area is accessible through the common area of the facility as a hallway veering off the entrance of the facility. 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 residents are kept in areas inaccessible to residents. There is a first aid kit that includes sterile dressings, bandages, thermometers, scissors, tweezers, and a first aid manual. As this facility has residents with dementia in care, there is a self-latching gate exiting the facility from the backyard to the front area for dementia residents. There is a fountain in the backyard which is filled with rocks and does not contain water, and an additional shaded gazebo with furniture for resident use. The facility has an outdoor storage area/building that remains locked and inaccessible to residents. LPA observed the interior of the storage shed/building. Continued on 809-C

RECORDS: The facility keeps confidential storage of personnel records and resident records on-site at the facility. The facility administrator meets the qualifications as specified in Title 22 regulations, with an active RCFE administrator certificate that expires 05/03/2025. 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. 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. Continued on 809-C

MEDICATIONS: The facility maintains a locked centralized storage area for resident medications. The centrally stored medications are stored in locked cabinets in the kitchen area of the facility. The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record. Centrally Stored Medications are in a locked area of the facility inaccessible to residents with staff having keys. LPA observed the medications for residents 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 postings throughout the facility, including emergency exit plans with necessary telephone numbers. The facility maintains documentation on site prominently posted in areas accessible to residents and their visitors. Provider Information Notices are available and able to be presented to Staff, residents, visitors, and accessible to LPA.

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