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. The facility has an approved Hospice Waiver for three (3) residents.

The LPA inspected the food service area in the facility and observed that items which could constitute a danger to residents are kept inaccessible to residents. 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 residents 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/resident 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 resident 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. Each resident has adequate dresser and closet space for clothing and other belongings that includes at least two drawers or adequate dresser space. The facility has a sufficient supply of linens to permit weekly changing or more often to always ensure clean linens for residents. Equipment and supplies for resident personal hygiene is available and on site. Activity supplies are available for residents. Continued on 809-C

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. At the time of the visit, all common areas/interior rooms of the facility were observed to be appropriately furnished, with all furniture in good condition. The facility common areas include communal restrooms in the hallways, resident bedrooms, a resident activity room, locked laundry room, locked/staff only kitchen area, dining room, locked food storage/pantry, locked closet areas in the hallways containing the storage of clean linens, PPE materials, resident hygiene products, and activity materials. 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. 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 as the facility is one (1) story, there are no stairwells/stairs for resident use. Carbon monoxide detectors were operational at the time of the visit. Fire extinguishers were fully charged and serviced annually. 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 resident use. The facility maintains the use of electronic combination locks on areas inaccessible to residents. Continued on 809-C

The facility restrooms were sanitized and in operating condition while the LPA toured the facility. All restrooms in the facility were sufficiently stocked with soap, paper towels, required postings, and clean trashcans with closed lids. Towels and washcloths are not shared by residents in the facility. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per Title 22 regulations between 105-120 degrees Fahrenheit. All toilets and hand washing areas are maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences are available accommodate any physically handicapped residents who need such items. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Each resident bedroom has a bed, nightstands, and lights and nightstand lamps to provide sufficient lighting. Each closet in all the resident rooms can store or 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 assisting device a resident might need such as a wheelchair or a walker. Each room has sufficient lighting for each resident. The facility has provisioned to each resident of furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. All restrooms in the facility are in the interior of each individual resident bedroom. Continued on 809-C

Exit interview conducted by LPA. Copy of this report provided to the facility.