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 Day Program (ADP) facility with an approved fire clearance capacity of thirty (30) clients with an age range of 18 years and older. The facility is approved for up to five (5) non-ambulatory clients. There are no bedrooms in the facility, as this is an ADP. The schedule of the facility consists of business hours from 8:30am-4:00pm on Monday, Tuesday, Wednesday, and Friday. The facility is closed to clients on Thursday, Saturday and Sunday. The clients receive a breakfast served by the facility daily, as well as a lunch and an afternoon snack between 2:30pm-3:00pm daily. The facility has alternating/rotating daily activities and events including a pianist who performs for the clients, trivia games, and group activities for the clients.

COMMON AREAS: At the time of the visit, all indoor common areas of the facility were observed by LPA to be in good condition with no observable damage to the physical plant of the facility nor any observable hazards to clients. All furniture in the facility was observed by LPA to be in good condition with no need of repair. There is a fireplace in the living room, which is covered and inaccessible. There are activity supplies and equipment, including reading materials for the clients. The facility maintained a comfortable temperature in all areas inspected/observed by LPA. Smoke detectors and carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguishers in the facility were fully charged and were last serviced in 2024. All window screens were in good repair in all the areas comprising the facility. There is appropriate lighting in all the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, well-lit, with the facility having no indoor stairways needing sturdy hand railings/accessibility devices. There is adequate space available for storage of clients' personal belongings. Continued on 809-C

KITCHEN/FOOD SERVICE PREPARATION: The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored inaccessible to clients. The food service area consists of a locked cafeteria style kitchen, which is a separate indoor room connected to the main living room area. The kitchen is accessible for employees by two doors with a viewing window in between, having a pull-down shutter. During the business hours of the ADP when clients are in the facility, the two doors to the kitchen are locked and the shutter is opened, allowing clients to observe the kitchen area, but making the sharp instruments, heating elements, and cleaning materials inaccessible to clients. The administrator demonstrated this to the LPA, which was observed by the LPA. 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. Additional perishable food items were maintained on a shelf and/or a freezer. The hot water temperature was measured in the kitchen at an appropriate temperature as per Community Care Licensing (CCL) regulations. The food service area 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 used in this common area are kept in a separate area than the food supplies. The freezer and refrigerator were both in the appropriate temperate Fahrenheit per CCL regulations. There is enough tableware and utensils for all clients living in the facility, and enough equipment for the storage, preparation, and service of food.

BACKYARD/OUTDOOR ACTIVITY AREA/ETC.: The backyard/outdoor activity area of the facility is completely enclosed by a metal gate/fence with unlocked latches and gates. There is a side gate from the facility, which is not delayed egress self-closing, but all clients are supervised by staff when they are in the outdoor activity area. The backyard of the facility is equipped with furniture for client use including shaded tables, chairs, as well as a swing set and playground equipment (slide, etc.). The LPA did not observe any bodies of water on the physical plant of the facility. The backyard of the facility has a door into the main living room/common area of the facility as well as doors leading to the administrator’s office and staff areas inaccessible to the clients. There is no designated laundry room and/or service as this facility is an ADP with no laundry service as per the Program Plan of Operation. Continued on 809-C

RESTROOMS: The facility restrooms were sanitized and in operating condition while the LPA toured the facility. There are two (2) restrooms in the facility, consisting of one (1) male restroom and one (1) female restroom in the indoor hallway of the facility. All restrooms inspected 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 between 105-120 degrees Fahrenheit. There is no need for nightlights having to be installed in the hallways outside of the common area restrooms as this facility is an ADP with operating business hours between 8:30am-4:00pm for clients. 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 who need such items.

RECORDS: The facility keeps confidential storage of personnel records and client records on-site at the facility. The program administrator meets the qualifications as specified in Title 22 regulations. Additionally, the program administrator receives and documents continuing education each year. Personnel records reviews were reviewed for, but not limited to Personnel records, Health assessments with Tuberculosis (TB) test results, Personnel Action Notice, Job Description with date of employment, Employee Rights, Criminal record Statements, Criminal record clearances, First aid/CPR certification that is not expired, and the appropriate training documentation. Client records were reviewed for Pre-Admission/Placement appraisals, Admission Agreements, Physicians Reports, Consent Forms, Personal Rights for Residents, Emergency Information, Release of Medical Information, Needs and Services Plan (ANS)/Individual Program Plan (IPP), Resident Assessments, Self-management of medications if applicable, Medication Orders, and Medication Logs. The facility complies with Community Care Licensing (CCL) standards for health screening, TB clearance, staff training, criminal background clearance and transfer requests. Client records including Admission agreements and Needs and Services plan are maintained for each Client and/or their authorized representative.

Continued 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 postings throughout the facility, including emergency exit plans with necessary telephone numbers. The facility maintains documentation on site such as the Fire Department Clearance, Personnel Report, Plan of Operation, Emergency Disaster Plan, Facility Infection Control Plan/Mitigation Plan, Evacuation Procedures, Personal Rights of Clients, and a Facility Sketch. Provider Information Notices are available and able to be presented to Staff, clients, visitors, and accessible to LPA. Facility documentation is prominently posted in areas accessible to clients and their visitors.

At the time of the previous annual site inspection in 2023, the administrator of the facility informed the LPA that the facility was in the application process for a change of location to move the facility from the current inspected location to another building within the same general area. This Change of Location (CHOL) License application was in an ongoing status at the time of the 2023 Annual Facility inspection by the LPA. As of this current annual site inspection in 2024, the CHOL request was withdrawn due to the potential new location not having any type of sprinkler system, fire extinguishers, or any fire safety protection. The administrator stated that the facility will remain at the current location.

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