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). This facility is approved for a maximum capacity of six (6) residents. All residents are licensed for non-ambulatory status. The facility has an approved hospice care waiver with the licensing agency for two (2) residents.

The LPA inspected the food service areas in the facility and observed that items which could constitute a danger to residents are kept inaccessible to residents in the kitchen area. 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. Continued on 809-C

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 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 all inclines are well-lit with no stairwells/stairs for resident use, only ramps. There is a fireplace on the premises, which is covered and inaccessible to residents. Carbon monoxide detectors were operational at the time of the visit. The fire extinguisher was 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 has adequate storage of additional supplies/emergency supplies. The designated laundry area in the facility has appropriate storage of cleaning products, which are kept locked and inaccessible to residents. Emergency food and water in storage were observed to be in good condition by the LPA. Cleaning supplies, disinfectants, and other items that could pose a danger are kept in areas inaccessible to residents. Vehicles used to transport residents are in safe operating condition with appropriate insurance information.

The facility restrooms were sanitized and in operating condition while the LPA toured facility. Contd. 809-C

An emergency exiting plan and emergency phone numbers are posted in an appropriate place. First-aid supplies, which include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual, are maintained. Administrator’s records, employees and resident records are maintained at the facility and available for review by the LPA as employees are hired and residents accepted into the facility. The facility complies with CCL standards for health screening, TB clearance, staff training, criminal background clearance and transfer requests. Admission agreements and needs and services (ANS) plan are maintained for each resident and/or their authorized representative. Resident records are maintained on the facility premises in a secured area. Centrally stored medications are locked inaccessible to residents. The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record. The facility administrator meets the qualifications as specified in Title 22 regulations with an active RCFE administrator certificate that expires on 06/28/2026. Provider Information Notices are available and able to be presented to Staff, residents, visitors, and accessible to LPA upon request during the inspection process. Facility was observed by LPA to have appropriate/adequate delayed egress measures in place for residents with dementia/cognitive decline.

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