The LPA toured all physical plant areas to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. This is an Adult Residential Facility (ARF), with an approved fire clearance capacity of four (4) clients. The physical plant of the facility contains four (4) bedrooms, two (2) bathrooms, kitchen/dining area, two (2) living rooms and laundry room. There is an outside area in the back, side and front for clients to utilize for outdoor activities with furniture and a shaded patio in the backyard. The facility fire clearance approves two (2) ambulatory residents in client bedroom #3. Client bedrooms #1 and #2 are approved for non-ambulatory clients. Bedroom #4 in the facility is for Staff use only.

KITCHEN: The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in locked drawers inaccessible to clients. 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 storage area in the garage of the facility as well as an extra refrigerator and extra freezer located in the garage of the facility. 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 clients are kept inaccessible to clients in 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. Continued on 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 are no fireplaces in the facility. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The facility has two (2) fire extinguishers that were fully charged and serviced annually. This is a single-story facility with a main dining room/kitchen area, 2 living rooms, a laundry room, 3 client bedrooms, 1 Staff bedroom, 2 client restrooms, a locked centrally stored medication containment area, and extra storage area for additional perishable food with additional appliances constituting the interior areas of the facility. The LPA observed required postings throughout the common spaces including Client Personal Rights and Contact information for Ombudsman as well as Licensing. There are activity supplies and equipment, including activity materials for the clients such as bicycles, 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 client use. There is a slight incline in the interior of the facility, between the kitchen and living room area, marked by a sign that indicates to watch your step. The incline is very slight with no ramp needed.

OUTSIDE/LAUNDRY/MISCELLANEOUS: The front outdoor area of the facility consists of a walkway around a front lawn into the front door. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. Outdoor activity spaces are completely enclosed by a wooden fence and gates. The facility has an outdoor activity area that is provided with a shaded area and furnished for outdoor use. There were no bodies of water noted. The designated laundry area is where cleaning products are stored, which are kept locked and inaccessible to clients. The laundry room is accessible as a door from one of the living rooms of the facility as a specific room which has all hazardous items locked with padlocks. There was emergency food and water in a storage area pantry next to the kitchen 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 clients are kept in areas inaccessible to clients. There is a first aid kit that includes sterile dressings, bandages, thermometers, scissors, tweezers, and a first aid manual. The vehicles used to transport clients are in safe operating condition with appropriate insurance information. Continued on 809-C

BEDROOMS: The LPA observed the client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are designated individual client rooms in the facility with only one (1) client per bedroom. The bedrooms have storage areas for clean linens, towels, pillows, etc. Each client’s bedroom has a single bed, nightstand, and lights/nightstand lamps to provide sufficient lighting. Each closet in all the client rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any client. The client bedrooms are big enough for all beds, furniture, and any client assistive device a client might need such as a wheelchair or a walker. Each room has sufficient lighting for each client.

RESTROOMS: The facility restrooms were sanitized and in operating condition while the LPA toured the facility. There are two (2) client bathrooms in the facility. All restrooms inspected had assistive equipment for clients 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 both the client restrooms.

RECORDS: The facility keeps confidential storage of client records as well as Staff member records on-site at the facility. Staff member records 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. All staff members’ personnel records had the appropriate documentation with no expiration of any training. Client records were reviewed for Pre-Admission/Placement appraisals, Physicians Reports, Consent Forms, Personal Rights for Clients, Emergency Information, Release of Medical Information, Needs and Services Plan (ANS) and/or Individual Program Plan (IPP), Client Assessments, Self-management of medications if applicable, Medication Orders, and Medication Logs. All client records reviewed by the LPA had the appropriate documentation with no missing or incomplete information. 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 required postings throughout the facility, including emergency exit plans with necessary telephone numbers. The facility keeps hard copies of facility documentation such as LIC 500 Personnel Report, LIC 501 Personnel Record, LIC 610D Emergency Disaster Plan for Adult Residential Facilities, LIC 9282 Adult Residential Infection Control Plan, and LIC 999 Facility Sketch. Provider Information Notices are easily accessible and presented to LPA upon request during the inspection process.

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