At 9:20 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 or cooking in progress at the time. LPA checked the appliances and observed them in working order. 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 9:24 AM, LPA observed knifes, bleach solutions, comet bleach, disinfectants, and cleaning chemicals in an unlocked closet underneath the kitchen sink and accessible to residents in care.

LPA inspected the den area and observed it clean. There was a fireplace with a screen cover, sofa chairs and computer workstation. There was a dining area next to the den and found it clean containing a dining table, and dining chairs to accommodate all the residents. LPA inspected the family room and observed it clean, with all the furniture in good repair. There was a sofa set, chairs, TV, and a Christmas tree.

LPA inspected the fire extinguisher mounted on the wall next to the dining area and found it fully charged with a last service tag of 04/09/2024. 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

LPA inspected bathroom and found it clean, sanitary, and in good working condition. It contained soap, paper towels, a non-slip mat, a trash can, and non-slip flooring. The hot water temperature at the sink faucet was measured at 119.8°F.

LPA inspected the garage and found it clean. LPA observed an operational washer and dryer, refrigerator, freezer, shelves with non-perishable food items and paper products.

LPA toured the backyard area and was observed in good condition. The backyard has a set of a patio table, chairs, and umbrellas for resident use. There were no bodies of water noted and was found clear of obstructions.

LPA reviewed (2) 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 2 of 2 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 2 of 2 staff members are associated with the facility.

LPA inspected the first aid kit and observed it fully stocked. The administrator counted Resident P&I money in front of the LPA and records indicated the correct amount.

LPA observed a locked centrally stored medication in computer table cabinet located in the den 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.

At 10:23 AM, LPA reviewed Emergency Drill Logs and observed drills are not conducted every six months with the last drill conducted on 03/09/2024.

Continued on LIC 809-C

• LIC 500: Personnel Report
• LIC 308: Designation of Facility Responsibility
• LIC 610D: Emergency Disaster Plan
• LIC 400: Resident's Cash Resources
• Control of Property
• Infection Control Plan
• Certificate of Liability Insurance
• Surety Bond
• Administrator Certificate(s)

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