At 8:55 AM, the LPA initiated a walk-through of the facility, accompanied by the Manager.

LPA inspected the kitchen and found it clean, with no food preparation or cooking in progress at the time. Manager stated that appliances in the kitchen are for staff use only. No meals are prepared for the residents in care. All residents eat though tubes. The locked cabinet containing knives and the locked cabinet under the sink with soap and cleaning supplies were also inspected. LPA inspected the refrigerator and observed a locked box for storing rectal suppositories.

LPA inspected the dining area and observed it clean, with all the furniture in good repair. LPA inspected the fire extinguisher mounted on the wall in the kitchen and found it was fully charged with a last service tag of 06/26/2024. The manager tested the smoke and carbon monoxide detector located in the hallway in the LPA's presence, and it was found to be functional. LPA inspected the living room and observed activities calendar posted with list of activities for each day.

There are (5) bedrooms and (1) bathroom designated for residents' use, and (1) bathroom designated for staff, and (1) office room. All resident rooms are private occupancy. LPA inspected all (5) resident rooms and found them clean, well-lit, and equipped with the required furniture. Each resident room contained resident’s incontinence, respiratory, and linen supplies.

LPA inspected the common resident bathroom and found it clean, sanitary, and in operating condition. It contained shower gurney, shower curtain, soap, grab bars, a trash can, and non-slip flooring. The hot water temperature at the sink faucet was measured at 109.2°F.

Continued on 809-C

LPA inspected the garage and observed a van parked used to transport residents. The garage contained feeding, incontinence, and respiratory supplies, and emergency suitcases with items needed for each resident.

LPA toured the backyard area. The backyard has a shaded patio with set of a patio table and chairs. There were no bodies of water noted. Exit routes were found clear of obstructions.

At 9:50 AM, the LPA observed a centrally stored medication cabinet located inside the locked cabinets in the kitchen. Medications were organized in separate bins for each resident. 1 of 4 resident’s medication prescription numbers were entered incorrectly in the Centrally Stored Medication Records (CSMR). 1 of 4 resident’s medication prescription numbers were not entered in CSMR. 1 of 4 resident’s medication prescription labels were altered with the handwritten dates on it using a black marker pen.

The LPA reviewed (4) staff personnel records and (4) resident records. The LPA observed that 4 of 4 clients had the Admission Agreement, Physician's Report, Appraisal Needs and Services Plan. LPA observed that 4 of 4 staff members had First Aid/CPR training, LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 4 of 4 staff members are associated with the facility.

LPA inspected the first aid kit and observed it fully stocked. LPA reviewed Emergency Drill Logs and observed Emergency Disaster Drills were conducted monthly, with the most recent drill completed on 12/07/2024. The Manager counted Resident’s P&I money in front of the LPA and records indicated the correct amount.

The following updated forms are requested to be submitted to CCLD by 12/27/2024:

• LIC 500: Personnel Report
• LIC 308: Designation of Facility Responsibility
• Certificate of Liability Insurance

• Surety Bond
• Current Property Lease
• Administrator Certificate(s)

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