LPA toured the physical plant in the presence of the Administrator. The facility was observed to be clean, in good repair, and maintained at a comfortable temperature with adequate lighting. During the tour, two staff and six residents were present. The residents were observed eating lunch on the outside deck, sitting in the living room, and watching TV. The facility sketch includes 5 resident bedrooms, 2 bathrooms, 1 staff room, a living room, a kitchen with dining, a laundry area, a garage, and 7 exit doors for access to the exterior area of the facility. No tripping hazards were observed.

At 12:45 PM, LPA observed a private caregiver (PC1) present at the facility. PC1 is hired by the resident (R1)'s responsible party. PC1 didn't have fingerprint clearance and was not associated with the facility, which poses an immediate health, safety or personal rights risk to persons in care.

At 12:56 PM, LPA inspected all residents’ bedrooms (4 private and 1 shared) and observed them to be clean with sufficient furniture and operational light fixtures. The auditory alarms were operational on all exit doors. The bathrooms were observed to be clean and contained non-skid mats, grab bars, trash cans, liquid soap, and paper towels. The bath area had a shower curtain and a shower chair. The bathroom faucet hot water temperature was measured at 118.2°F.

At 1:12 PM, LPA inspected the kitchen and observed it to be clean. Toxins, cleaning supplies, and sharp objects were stored/locked properly and inaccessible to residents. The facility had an adequate stock of food items, including 7 days of non-perishables and 2 days of perishables. No expired food items were observed.

At 1:23 PM, LPA inspected the garage and observed two staff units constructed in the garage. The facility sketch doesn't show these two units and the Administrator doesn't have permits/clearance for the construction, which poses an immediate health, safety or personal rights risk to persons in care.

At 1:36 PM, LPA inspected the laundry area and observed it to be clean, equipped with a washer and dryer.

At 1:54 PM, LPA inspected the fire extinguishers, which were observed to be fully charged and last serviced on April, 2024. The smoke and carbon monoxide detectors were tested and observed to be operational.

At 2:12 PM, LPA reviewed five resident and five staff records. All were observed to be complete.

At 2:23 PM, LPA audited the Medication administration records and observed them to be accurate. Resident medications were securely stored in a locked cabinet in the kitchen. No expired medications were observed.

At 2:28 PM, LPA inspected the First Aid kit and observed it to contain required supplies. Emergency drills are conducted quarterly.

The following updated forms are requested to be submitted to CCLD by 10/10/2024:

An exit interview was conducted. This report was reviewed with Victoria Regala, Administrator, and a copy of this report along with appeal rights was left at the facility.