A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit:

Physical Plant & Environment Safety: The fire extinguishers were last charged and inspected on April 15, 2025. The residence currently occupies three (3) clients, the facility has three (3) bedroom and three (3) bathrooms. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors that were tested. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid surfaces. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectants and cleaning solutions are inaccessible to residents in care and are locked and stored in the laundry room, storage closet in hall, and/or locked under kitchen sink. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use with plenty of shade. The facility has telephone and internet service for resident use.

Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity of 3.

Continued 809-C

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidential. Facility does submit incident reports to the department when required. LPA reviewed 3 resident files, files included Physician reports, Service Plans, Annual reviews, and admission agreements.

Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables to meet the food service requirement. All food is covered, stored, and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies.

Incidental Medical Services: Facility provides transportation or assists in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR), a review of the medication processes, counts, documentation, destruction, and passing process was discussed. No prescription medications were expired, and all medications were kept in their original containers.

Disaster Preparedness: The current emergency disaster forms were posted. The Facility last conducted a quarterly disaster drill on June 22, 2025. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency.

Residents with Special Health Needs: The facility has eight (8) gates six (6) in the back yard and two (2) in the front leading to the main street. Facility exit door alarms are working at time of visit.

Exit interview conducted and copy of report printed for Administrator.