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 Three (3) Non-Ambulatory clients in bedrooms #1, #2, and #3.

KITCHEN: The facility maintains a kitchen room/area within the interior of the facility. The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in a locked cabinet next to the centrally stored medications inaccessible to clients. This cabinet is adjacent to the kitchen in the dining room area of the facility. 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). The hot water temperature was measured in the kitchen at an appropriate temperature as per the regulation between 105-120 degrees Fahrenheit. All items that could constitute a danger to clients are kept inaccessible to clients in the kitchen area. The kitchen was clean and sanitary, with covered trashcans and operating ventilation systems. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. The freezer and refrigerator were both the appropriate temperate Fahrenheit for the storage of food and prevention of spoiling. There is enough tableware and utensils for all clients living in the facility, and enough equipment for the storage, preparation, and service of food.

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. Continued on 809-C

OUTSIDE/LAUNDRY/MISCELLANEOUS: The facility outdoor areas are maintained with observable landscaped grass areas and a clean exterior building. However, LPA noticed a large screw in the front door of the facility sticking out approximately 2 to 3 inches at eye level when entering the facility which is an observable hazard to clients in care. The backyard/patio room is conducive for outdoor visitation. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. The backyard of the facility has an outdoor/outside activity area for clients with a patio in the backyard, furniture, and shade. The backyard has a covered outdoor area equipped with furniture for resident use. The side gate is self-closing. There were no bodies of water noted. There is a separate laundry room in the garage area, which is kept locked. The garage is accessible through the laundry room. There was emergency food and water in the garage which was observed to be in good condition. Cleaning supplies and disinfectants are kept in locked cabinets in the garage. Laundry cleaning products are stored locked and inaccessible to clients. Cleaning supplies, disinfectants, and other items that could pose a danger to clients are kept in areas inaccessible to clients. There is a first aid kit that includes sterile dressings, bandages, thermometers, scissors, tweezers, and a first aid manual. The vehicles used to transport clients are in safe operating condition with appropriate insurance information. There is a main entrance walkway into the facility and an administrative entrance area for visitors. Continued on 809-C

RESTROOMS: There are Two (2) facility restrooms, a communal client restroom in the facility hallway and an individual client restroom in a bedroom. Facility restrooms were sanitized and in operating condition while the LPA toured the facility. All restroom areas inspected had assistive equipment for clients including grab bars and/or non-skid surfaces. The restrooms were sufficiently stocked with soap, paper towels, and additional supplies; towels and washcloths are not shared. The hot water temperature was measured in the restrooms within the appropriate temperature regulations. Nightlights are installed in the hallways outside of the client restrooms. The restrooms had sufficient required postings.

RECORDS: The facility keeps confidential storage of client and Staff records on-site at the facility. Staff records were reviewed for, but not limited to Health Screening Report/Tuberculosis (TB) Clearance for facility personnel, Personnel Record (employment application), verification of age over 18 years old, education, and experience, approved Certification for the Administrator, verification of first aid training, Criminal Record Statement, Criminal Record Clearance/Exemption, Verification of Staff training, Employee Rights, and Abuse Reporting Requirements. All staff members’ personnel records reviewed by LPA had the appropriate documentation. The administrator of the facility has an active Adult Residential Facility (ARF) Administrator Certificate that will expire on 09/29/2024. Client records were reviewed for, but not limited to Pre-Admission/Placement appraisals, Client Appraisals, Appraisal Needs and Services Plan (ANS) and/or Tri-Counties Regional Center Individual Program Plan (IPP), Physicians’ Reports, Identification and Emergency Information, Current Admission Agreement with signatures, Personal Rights for Clients, Record of Clients safeguarded cash resources, Record of Client personal property/valuables, Responsible Person or Conservator of Client, Self-management of medications if applicable, Medication Orders, and Medication Logs. All client records reviewed by the LPA had the appropriate documentation with no missing or incomplete information.

MEDICATIONS: Facility maintains locked centralized storage area for client medications. Contd. on 809-C

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 required postings throughout the facility, including emergency exit plans with necessary telephone numbers. The facility keeps posted copies of facility documentation such as the Adult Residential Facility (ARF) License Certificate, LIC 500 Personnel Report, Documentation of Facility Waivers, Plan of Operation, Emergency Disaster Plan for Adult Residential Facilities, Facility Infection Control Plan/Mitigation Plan, 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. All vehicles used to transport residents are maintained in safe operating condition. On the facility Emergency and Disaster Plan, the facility has Three (3) temporary shelter locations, but all 3 are within the immediate area. Administrator agreed to change one location to outside of the immediate area.

LPA noted that a technical violation and technical assistance were issued during this annual facility site inspection. However, no citations were issued during this annual inspection at this time.

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