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, of which six (6) may be bedridden. The facility has an approved Hospice Waiver for four (4) residents. The physical plant of the facility contains a living room, family room, kitchen, dining room, Staff room, breakfast area, office room, laundry room area, garage, and six (6) private resident bedrooms available for individual residents with no shared bedrooms. There are three (3) restrooms within the facility, all containing both toilets and bathtub/shower. The facility contains an outside area for residents to utilize for outdoor activities/outdoor visitations with a shaded outdoor covered patio area appropriately furnished for outdoor use.

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 pantry storage area in the of the facility. The facility stores extra perishable and non-perishable food in the garage of the facility with cabinets of food, an extra refrigerator and extra freezer located in the garage area of the facility. The hot water temperature was measured in the kitchen at 100 degrees Fahrenheit, a level slightly below the appropriate temperature as per the regulation between 105-120 degrees Fahrenheit. Continued 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 family room of the facility that is covered and 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 fire extinguishers that were fully charged and serviced annually, all being tagged as serviced in February 2023. This is a single-story facility with a main living room area, kitchen area, dining room, laundry room, family room, breakfast area, Staff office, Staff room, 6 resident bedrooms, 3 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 room area for the facility is in a locked addendum/room area between the family room and the garage 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 interior common areas including the living room and dining area are neat and clean. The facility maintains a comfortable temperature. Doors, stairways, and passageways are unobstructed. Walls, ceilings, floors, carpeting, window screens, and areas around the facility are clean, painted and/or in good repair. Furniture is appropriate for each room, clean and in good repair. Continued on 809-C

OUTSIDE/LAUNDRY/MISCELLANEOUS: The front yard is well maintained and consists of cement walkways and grass areas. The backyard is well maintained and has a covered patio area with outdoor furniture and shade, 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 and/or fence around the entire facility with latched gates. Inside of the perimeter is the outdoor/outside activity area for residents with a gazebo/patio in the backyard, furniture, shade, and a small shed that is locked with a padlock that contains storage of outdoor maintenance materials for the facility. LPA was shown the inside of the shed upon request. The facility has an outdoor activity area that is provided with a covered shaded patio area and furnished for outdoor use. There are no bodies of water noted on the facility property. The designated laundry area is a locked room within the facility in between the family room and garage, inaccessible to residents. Cleaning products and hazardous/poisonous products for laundry are stored in locked cabinets which are kept inaccessible to residents. Staff members are the only individuals allowed to do laundry and the entire room is kept always locked. There was emergency food and water in the garage storage area in the interior of the facility and in the extra perishable food storage area which was observed to be in good condition. Cleaning supplies, disinfectants, and other items that could pose a danger to residents are kept in areas inaccessible to residents. There is a first aid kit that includes sterile dressings, bandages, thermometers, scissors, tweezers, and a first aid manual. The vehicles used to transport residents are in safe operating condition with appropriate insurance information. LPA did not observe any noticeable outdoor hazards in areas accessible to residents. Electronic devices are in place to monitor exits out of the interior building in the facility, and a loud auditory noise goes off if a door that exits the facility to the outdoor areas is opened by any individual.

BEDROOMS: The facility contains six (6) individual resident bedrooms that are for a single resident per bedroom only. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Each resident bedroom has an adult bed or beds 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 an adequate dresser and closet space for clothing and other belongings. Continued on 809-C

RESTROOMS: There are three (3) resident restrooms in the facility. The facility restrooms were sanitized and in operating condition while the LPA toured the facility. All restrooms inspected had assistive equipment for residents 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 at the appropriate degrees Fahrenheit as per the regulations between 105-120 degrees Fahrenheit. Nightlights are installed in the hallways outside of the resident restrooms. All resident restrooms contain a sink, toilet, and bathtub and/or shower.

RECORDS: The facility keeps confidential storage of both resident and Staff member records on-site at the facility. Staff member 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, Driver’s License if transporting residents, and Abuse Reporting Requirements. All staff members’ personnel records reviewed by LPA had the appropriate documentation. The administrator of the facility has an active Residential Care Facility for the Elderly (RCFE) Administrator Certificate with an effective date of 08/20/2022, and an expiration date of 08/19/2024. Resident records were reviewed for, but not limited to Pre-Admission/Placement appraisals, Resident Appraisals, Appraisal Needs and Services Plan (ANS), Physicians’ Report for RCFE, Identification and Emergency Information, Current Admission Agreement with signatures, Personal Rights for Residents, Signed Resident Consent Forms, Record of Residents personal property and/or resident valuables, Physician Orders for Life Sustaining Treatment (POLST), Advance Health Care Directive Form, Responsible Person or Conservator of Resident, Self-management of medications if applicable, Signed PRN Authorization Letter if applicable, Medication Orders, Medication Logs, Signed release of resident medical information, and the Centrally Stored Medication and Destruction Record. Continued on 809-C

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 medication cart that always remains locked, inaccessible to residents. The LPA observed the resident medications as well as the Centrally Stored Medication and Destruction Record, The Medication Administration Record (MARS), 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.

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 RCFE License Certificate, LIC 500 Personnel Report, Documentation of Facility Waivers, Plan of Operation, Emergency Disaster Plan for Residential Care Facilities for the Elderly (RCFE), Facility Infection Control Plan/Mitigation Plan, Certificate of Liability Insurance, Valid Administrator Certificate, 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.