At 9:20 AM, the LPA initiated a walk-through of the facility, accompanied by the DSP.

LPA inspected the kitchen and found it clean, with breakfast preparation and cooking in progress at the time. The appliances were checked and observed to be in working order. The LPA inspected a locked cabinet containing knives and sharp objects, and a locked cabinet under the sink with detergents and cleaning supplies. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No expired food or stored medications were noted.

LPA inspected the dining area adjacent to the kitchen and found it clean. The dining table and chairs were observed to accommodate the residents, and all the furniture was in good repair. The LPA observed two residents eating breakfast with assistance from a caregiver at the dining table. The LPA inspected the living room and observed it clean, with all furniture in good repair. There was a set of couches and a television in the living room.

The LPA inspected the fire extinguisher mounted on the wall in the dining area and found it fully charged, with the last service tag dated 01/10/2025. The DSP tested the smoke and carbon monoxide detector located in the hallway in the LPA's presence, and it was found to be functional.

Continued on 809-C

LPA inspected both bathrooms and found them clean, sanitary, and in good working condition. The bathrooms contained soap, grab bars, paper towels, a trash can, a shower chair, and non-slip mats. The hot water temperature at the sink faucet measured 132.6°F in bathroom #1 and 133.4°F in bathroom #2.

LPA inspected the storage closet in the hallway and observed it contained clean linens and towels for residents’ use.

LPA toured the backyard area and found ramps and passageways in good condition, clear of obstructions, with no blocking or tripping hazards. No bodies of water were noted. The LPA inspected (1) storage shed and observed wheelchairs, blankets, pillows, memory foam toppers, and incontinence supplies stored inside.

LPA inspected the garage and found it clean. A washer and dryer unit, and a refrigerator and freezer containing additional food supplies, were observed.

LPA reviewed (5) staff personnel records and (5) resident records. The LPA observed that 5 of 5 residents had an Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, and CSDMR. 1 of 5 residents with Dementia had a last physician assessment completed on 09/11/2023. 1 of 5 residents was missing personal rights and consent forms. LPA observed that 5 of 5 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 5 of 5 staff members were associated with the facility.

LPA observed a locked centrally stored medication cart located near the dining area. Medications were organized in separate bins for each resident. All medication bottles were properly labeled. Centrally Stored Medication Records (CSMR) were reviewed and found to be complete.

LPA inspected the first aid kit and found it fully stocked. Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster Drills were conducted quarterly, with the most recent drill completed on 10/06/2024.

Continued on 809-C.

• LIC 500: Personnel Report
• LIC 308: Designation of Facility Responsibility
• Certificate of Liability Insurance
• Administrator Certificate(s)

An exit interview was conducted, and Plans of Correction were reviewed and developed with the DSP. A copy of this report and appeal rights were discussed and left with the DSP, Jocelyn Ternida, whose signature on this form confirms receipt of these documents.