At 9:12 AM, the LPA initiated a walk-through of the facility, accompanied by the Administrator.

LPA inspected the kitchen and found it clean, with no food 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. 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. (3) residents were observed eating breakfast. A fireplace covered with the glass enclosure and a credenza with the music system was observed in the dining area.

LPA inspected the living room and observed it clean, with all furniture in good repair. There were sofa sets, chairs, recliners, tables, and a television in the living room. (2) residents were observed sitting on the recliners taking nap.

LPA inspected the (2) storage closets in the hallway and observed them contained clean linens, blankets, and towels for residents’ use.

There were (6) bedrooms and (6) bathrooms designated for residents' use. All (6) resident rooms were single occupancy with private bathrooms. LPA inspected all (6) resident rooms and found them clean, well-lit, and equipped with the required furniture. All exit doors were connected to centrally monitored system for notification.

Continued on LIC809-C

LPA inspected the fire extinguisher mounted on the wall in the hallway next to kitchen and found it fully charged, with the last service tag dated 02/17/2025. The Administrator tested the smoke and carbon monoxide detector located in one of the resident’s rooms 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.

LPA inspected the utility room and found it clean. The access door to the utility room was locked and inaccessible to residents in care. A washer, a dryer, cabinets with detergents, disinfectants, and cleaning supplies, and cabinets with medications were observed inside the utility room.

LPA inspected the storage room and a refrigerator, a freezer containing additional food supplies, and storage shelves with non-perishable food items, incontinence supplies, and paper products were observed inside.

LPA toured the front porch and backyard areas, and found ramps and passageways in good condition, clear of obstructions, with no blocking or tripping hazards. The porch had a table, chairs, and shaded areas for resident use. No bodies of water were noted. LPA inspected (1) storage shed in the backyard and noted mattresses, bedframes, wheelchairs and outdoor furniture stored.

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. 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 cabinet inside the utility room. Medications were organized in separate bins for each resident. Centrally Stored Medication Records 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 02/17/2025.

Continued on LIC809-C

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

An exit interview was conducted with the Administrator. A copy of this report was left with the Administrator, Debbie Sazon, whose signature on this form confirms receipt of the report.