At 12:44 PM, the LPA initiated a walk-through of the facility, accompanied by the administrator.

At 12:45 PM, the LPA inspected the kitchen and found it clean, with no food preparation or cooking in progress at the time. LPA checked the appliances and observed them in working order. 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 pantry cabinets and observed enough supplies of fresh perishable food for (2) days and nonperishable staples for (7) days. No expired food and no stored medications were noticed.

At 12:56 PM, LPA inspected the dining area next to the kitchen and found it clean. There was a dining table, and dining chairs to accommodate all the residents.

At 1:00 PM, LPA inspected the family room, and observed it clean, with all the furniture in good repair. There was a fireplace with a screen cover, set of chairs, coffee table, and computer station. LPA inspected the living room and observed couches, TV, toys, games, and a non-slip rug.

At 1:04 PM, the LPA inspected the fire extinguisher mounted on the wall next to kitchen/family room and found it was fully charged with a last service tag of 02/27/2024. The administrator tested the smoke and carbon monoxide detector located in the hallway in the LPA's presence, and it was found to be functional. Additional smoke and carbon monoxide detectors were observed in all bedrooms and common areas of the facility during the visit.

Continued on LIC 809-C

At 1:15 PM, LPA inspected both bathrooms and found them clean, sanitary, and in good working condition. It contained soap, grab bars, paper towels, non-slip mat, trash can, shower stool/chair, and non-slip flooring. The hot water temperature at the sink faucet was measured at 108.7°F in bathroom #1 and 107.5°F in bathroom #2.

At 1:22 PM, LPA inspected the garage and found it clean. LPA observed a washer, dryer, refrigerator, freezer, pantry cabinet with food items, shelves with incontinence supplies, and locked cabinet for storing cleaning supplies and other chemicals.

At 1:26 PM, LPA toured the backyard area. The backyard has a set of a patio table, chairs, and an umbrella for resident use. Ramps were observed in good condition. There were no bodies of water noted and was found clear of obstructions.

At 1:32 PM, the LPA inspected the first aid kit and observed it fully stocked.

At 1:35 PM, the LPA reviewed Emergency Drill Logs and observed drills are conducted quarterly.

At 1:38 PM, The LPA reviewed (4) staff personnel records and (5) resident records. The LPA observed that 5 of 5 residents had the Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, and CSDMR. LPA observed that 4 of 4 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 4 of 4 staff members are associated with the facility.

At 1:52 PM, the administrator counted Resident P&I money in front of the LPA and records indicated the correct amount.

At 1:58 PM, the LPA observed a locked centrally stored medication cabinet located in the living room. 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.

Continued on LIC 809-C

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

No deficiencies were cited during today's visit.

An exit interview was conducted. A copy of this report was left with the Administrator, Naomi Apostol-Miles, whose signature on this form confirms receipt of the report.