Kitchen: The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. All food is covered, stored and marked appropriately. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Cleaning supplies and disinfectants are stored under the sink and in the garage, inaccessible to clients. Knives are stored in a locked cabinet in the kitchen.

Common areas: Living and dining room furniture were observed to be in good condition. Carbon monoxide detector was tested and operational at the time of the visit. LPA observed required postings throughout the common space. The backyard had a table and umbrella. No bodies of water noted. The washer and dryer are in a laundry room. The laundry room which access the garage is locked.

Restrooms: The three (3) restrooms were clean and sanitary and in operating condition with non-skid mats. The bathrooms were sufficiently stocked with soap and paper towels.

Bedrooms: There are four (4) resident rooms, which were furnished. Linen cabinets were located outside of the rooms, which stocked extra linens and towels.

Continued on 809-C

Records: LPA reviewed resident and staff records at 11:45 p.m. Four (4) resident files were reviewed for, but not limited to, the following: signed Admission Agreements, Medical Assessments / LIC 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. The facility does not handle cash resources.

The LPA reviewed four (4) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid certification. Administrator Certificate expires on 10/27/25. All files were complete. LPA reviewed 4 staff training records for Annual Training Requirements of 20 plus hours. Trainer met the requirements to train staff.

Medications: Medications are centrally stored and locked in a cabinet in the kitchen/living room. The medications records were reviewed and all residents in care had a Medication Administration Record (MAR) and a Centrally Stored Medication Destruction Record (CSMDR). LPA inspected medication cabinet for all prescription and PRN medications with Doctors orders. LPA reviewed a sampling of residents medications, no medications labels were altered, no expired medications, and medications were stored in original containers.

Disaster Preparedness: The current emergency disaster forms are accessible to staff and emergency phone contacts are posted. The facility conducts quarterly disaster drills. The fire extinguishers was charged and inspected in February of 2024. A set of keys is available for staff on all shifts to access full facility in an emergency.

Infection Control: The facility has an infection control plan The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

Exit interview conducted. A copy of the report was printed.