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 a Residential Care Facility for the Elderly (RCFE), with an approved fire clearance capacity of six (6) residents. The facility is approved for six (6) non-ambulatory residents with a Dementia diagnosis. The facility has an approved Hospice Waiver for three (3) residents. The physical plant of the facility contains a living room, kitchen, dining room, indoor hallway/passageways, live-in Staff room, and six (6) private resident bedrooms available for individual residents. No resident shares a bedroom, and each bedroom has a private restroom. The live-in staff room is off the hallway of the facility and always remains locked, inaccessible to residents. The facility contains an outside area for residents to utilize for outdoor activities/outdoor visitations and an outdoor patio/gazebo area with furniture and shade.

KITCHEN: The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in a locked drawer inaccessible to residents. 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 locked cabinet in the kitchen area of the facility as well as an extra refrigerator and extra freezer located in a locked room/addendum off of the hallway 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 residents are kept inaccessible to residents in the kitchen area. Continued on 809-C

COMMON AREAS: 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 facility, located in the living room of the facility that is covered an inaccessible to residents. 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. This is a single-story facility with a main living room area, kitchen area, dining room, laundry room, 6 resident bedrooms, 6 resident restrooms, a locked centrally stored medication containment area, extra storage areas for additional perishable food, cupboards in the hallways of the facility containing extra linen/bedsheets/pillows, and storage areas for resident personal hygiene equipment constituting the interior areas of the facility. The LPA observed required postings throughout the common spaces including Resident Personal Rights and Contact information for Ombudsman as well as Licensing. There are activity supplies and equipment, including activity materials for the residents 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 resident use. The laundry area for the facility is located in a locked addendum/room area off of the main hallway of the facility that is inaccessible to residents. There is a main entrance walkway into the facility and an administrative entrance area for visitors. The facility has electronic auditory systems on all doors that can exit the interior of the facility, with a loud noise when a door exiting the facility is opened. The kitchen, living room, and dining area are neat and clean. The facility maintains a comfortable temperature. Hallways, bedroom doors, and walls are in good repair.

OUTSIDE/LAUNDRY/MISCELLANEOUS: The front yard is well maintained and consists of walkways and garden areas. The backyard is well maintained and has a paved patio, gazebo, and garden areas with walkways surrounding the parameter of the facility. The backyard 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 latched gates. Continued on 809-C

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 in the facility with one (1) individual resident per bedroom. The bedrooms have storage areas for clean linens, towels, pillows, etc. Each resident’s bedroom has a single bed, nightstand, and lights/nightstand lamps to provide sufficient lighting. Each closet in all the resident rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. The resident bedrooms are big enough for all beds, furniture, and any resident assistive device a resident might need such as a wheelchair or a walker. Each room has sufficient lighting for each resident. All resident bedrooms contain their own private restroom within the bedroom area. All resident bedrooms contain sliding doors to the exterior of the facility, monitored by the auditory system in place by the facility that alerts Staff when a door exiting the facility has been opened.

Continued on 809-C

RECORDS: The facility keeps confidential storage of resident records as well as Staff member records on-site at the facility. Staff member records were reviewed for, but not limited to Personnel records, Health assessments/screenings 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, appropriate training, and Abuse Reporting Requirements. All staff members’ personnel records had the appropriate documentation with no expiration of any training. All three (3) Co-Administrators Certificates are current/valid. Resident records were reviewed for Pre-Admission/Placement appraisals, Admission Agreements, Physicians Reports with TB Clearance, Consent Forms, Personal Rights for Residents, Emergency Information, Release of Medical Information, Needs and Services Plan (ANS)/Resident Care Plan Report with Updates, Resident Assessments, Physician Orders for Life Sustaining Treatment (POLST), Responsible Person or Conservator of Resident, Self-management of medications if applicable, Medication Orders, Medication Logs, and Inventory of Personal Effects/Management of Resident Cash and/or Valuables/Property. The facility also keeps records of resident vital signs and a resident weight record for all resident files reviewed. All resident 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 resident medications. Centrally Stored Medications are in a locked storage containment area within the kitchen area of the facility, which is a set of cabinets that remain locked at all times, inaccessible/locked to residents. 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 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. Continued on 809-C

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

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