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 an Adult Residential Facility (ARF) with a fire clearance approval capacity of four (4) ambulatory residents only. On 07/02/2024, LPA was informed by administrator that the facility would be fumigated in August 2024 from 08/15/2024-08/17/2024. The Administrator provided LPA with the name and address of a hotel where the clients would be located during the fumigation process.

At the time of the visit, the common areas of the facility were observed to be appropriately furnished, with all furniture in good condition. The facility is a 1 story home with 3 client bedrooms, a master bedroom of the licensee, craft room, dining room, living room, storage room, kitchen, and laundry area/game room garage constituting the interior of the facility. The facility has three (3) restrooms, a kitchen, dining room, two (2) living rooms, one (1) Central Medication room (where medications are centrally stored and locked), a client craft room, Staff Office room, and Game room for the clients. There is a fireplace in the living room, which is covered and inaccessible. The facility maintained a comfortable temperature as observed by LPA. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguishers were fully charged and are serviced annually. The LPA observed required postings throughout the common spaces including Client Personal Rights and Contact information for Ombudsman as well as Licensing. There are activity supplies and equipment, including activity materials for the clients. 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. There is a Staff Office area in between the kitchen/dining room. Continued 809-C

The kitchen/food service area had all knives/sharp instruments stored in locked drawers inaccessible to clients. 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 as observed by LPA. Additional perishable food items were maintained in storage area in the garage of the facility as well as in extra refrigerator and extra freezer located in the garage 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 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 in the appropriate temperate Fahrenheit. There is enough tableware and utensils for all clients living in the facility, and enough equipment for the storage, preparation, and service of food. The facility previously had a chef that prepared food for the clients on a weekly basis. However, now the facility uses a delivery service of "meal kits" with all ingredients and directions included.

The front outdoor area of the facility consists of concrete steps and an open porch with tables and chairs. The front of the facility is contained by a stone/concrete wall with a gate that remains unlocked. 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 or walls. Outdoor activity spaces in the backyard are equipped with furniture for client use including a patio with an umbrella for shade. All outdoor areas with stairways, inclines, ramps, or open porches have accessibility ramps for clients, and are well-lit. There were no bodies of water noted. There is a jacuzzi built into the deck in the backyard, however the jacuzzi was observed by the LPA to contain no water and have a locked cover always maintained. A garage is located off the kitchen of the facility and contains both the laundry area, a game area for the clients, and additional supplies/emergency supplies. The designated laundry area of the garage is where cleaning products are stored, which are kept locked and inaccessible to clients. The laundry room area itself is accessible to clients. Continued on 809-C

The LPA observed the client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are three (3) designated individual client rooms in the facility, one (1) bedroom for the Licensee of the facility, and one (1) converted bedroom which is a storage area for clean linens, towels, pillows, etc. Each client bedroom has a single bed, nightstands, and lights and nightstand lamps to provide sufficient lighting. Each closet in all the client rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any client. The client bedrooms are big enough for all beds, furniture, and any client assistive device a client might need such as a wheelchair or a walker. Each room has sufficient lighting for each client.

The facility restrooms were sanitized and in operating condition while the LPA toured the facility. There are two (2) shared client bathrooms in the facility. One (1) client bathroom is located off the family room in the facility, and the other client bathroom is next to the dining room and front entrance of the facility. All restrooms inspected had assistive equipment for clients including grab bars and/or non-skid surfaces. The bathrooms 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 at the appropriate degrees Fahrenheit as per CCL regulations. As the facility only contains three (3) clients at the time of inspection, there is at least one (1) toilet and sink per 3 clients, and at least 1 bathtub/shower per 3 clients. Night-lights are installed in the hallways outside of the common area restrooms. All toilets and hand washing areas are maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences are provided by the ADP to accommodate any physically handicapped clients. Continued on 809-C

The facility maintains a locked centralized storage area for client medications. The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record. Centrally Stored Medications are in a locked cabinet off the kitchen/Staff office area inaccessible to clients. LPA audited the medications for clients 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.

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.

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 clients and their visitors. Provider Information Notices are available and able to be presented/accessible to LPA.

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