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) Non-Ambulatory residents, of which One (1) may be bedridden in Room #4 only. The residents have an age range of sixty (60) years of age and older. The facility has an approved Hospice Waiver for Six (6) Residents. The facility contains an outside area for residents to utilize for outdoor activities/outdoor visitations and an outdoor patio area with furniture and shade.

KITCHEN: The facility maintains kitchen room/area for the facility that is open to include a dining room area. The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in a locked drawer inaccessible to residents in the garage of the facility. 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). 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 residents are kept inaccessible to residents outside of 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 the appropriate temperate Fahrenheit for the storage of food and prevention of spoiling. There is enough tableware and utensils for all residents living in the facility, and enough equipment for the storage, preparation, and service of food. Continued on 809-C

COMMON AREAS: The indoor areas of the facility consists of resident bedrooms, restrooms, shower areas, a Centrally Stored Medication area, kitchen, dining room, storage area closets/rooms, living room, Staff room/area and an entrance area upon entry into the facility. 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 are no fireplaces in the facility. 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 a fire extinguisher that was fully charged and serviced annually, being tagged as serviced in 2024. This facility contains a locked centrally stored medication containment area/closet, extra storage areas for additional perishable food, closets/rooms 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 area for the facility is located in 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 kitchen, living room, and dining area are neat and clean. The facility maintains a comfortable temperature. Hallways, bedroom doors, and walls are in good repair. A locked medication closet inaccessible to residents and First Aid Kit were observed to be complete.

OUTSIDE/LAUNDRY/MISCELLANEOUS: The front outdoor area of the facility consists of cement walkways and grass areas. The facility outdoor front yard area is paved with a walkway up to the front door of the facility. The back yard has a patio with shade and outdoor furniture 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 fence around the backyard area of the facility. Inside of the perimeter is the outdoor/outside activity area for residents with a patio in the backyard, furniture, shade. The facility has an outdoor activity area that is provided with a shaded area and furnished for outdoor use. There are no bodies of water noted on the facility property. Continued on 809-C

BEDROOMS: The facility has Five (5) resident bedrooms, both individual bedrooms for one (1) resident and shared bedrooms for two (2) residents. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. All resident bedrooms were furnished and contained beds, chairs, bedside tables and lamps. All beds have sheets, pillows, and mattress pads. There is also an ample supply of linens and towels. The bedrooms have storage areas for clean linens, towels, pillows, etc. Each resident’s bedroom has a single bed or beds, nightstand, and lights/nightstand lamps to provide sufficient lighting. Each closet in all the resident rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. The resident bedrooms are big enough for all beds, furniture, and any resident assistive device a resident might need such as a wheelchair or a walker. Each room has sufficient lighting for each resident. All resident bedrooms have sliding doors into the backyard of the facility, monitored by auditory alarms if the sliding doors are opened to alert the Staff members of the facility.

RESTROOMS: There are three (3) resident restrooms in the facility. Two (2) of the restrooms are specifically for resident use, while one (1) restroom is used primarily by Staff members/caregivers. The facility restrooms were sanitized and in operating condition while the LPA toured the facility. All restrooms/showers 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. Continued on 809-C

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, and Abuse Reporting Requirements. All staff members’ personnel records reviewed by LPA had the appropriate documentation. The administrator of the facility has a Pending Residential Care Facility for the Elderly (RCFE) Administrator Certificate from a previously Active Administrator Certificate, with payment received. 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, Record of Residents safeguarded cash resources and/or Record of Resident personal property/valuables, Physician Orders for Life Sustaining Treatment (POLST), Responsible Person or Conservator of Resident, Self-management of medications if applicable, Medication Orders, and Medication Logs. Additionally, the facility keeps records of resident(s) weight as well as resident dietary restrictions. All resident records reviewed by the LPA had the appropriate documentation with no missing or incomplete information.

MEDICATIONS: The facility maintains a locked centralized storage area for resident medications. Centrally Stored Medications are in a locked storage containment area within an indoor closet area of the facility, which remains locked at all times, inaccessible/locked to residents. The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record, The Medication Administration Record, 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.

Continued on 809-C

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.