At 12:18 PM, 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. 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 refrigerated medications were noticed.

LPA inspected the dining area and observed it clean, with all the furniture in good repair. There was a dining table and enough chairs to accommodate all the residents. Games, arts, and crafts supplies for the resident’s activities were observed in the dining area credenza. The LPA inspected the fire extinguisher mounted on the wall in the kitchen and found it was fully charged with a last service tag of 10/28/2024. 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.

There are (4) bedrooms and (3) bathrooms designated for residents' use. (3) resident bedrooms are private and (1) resident bedroom is shared occupancy. (2) Resident bedrooms have private bathrooms. LPA inspected all (4) resident rooms and found them clean, well-lit, and equipped with the required furniture.

Continued on 809-C

LPA inspected the laundry room and observed a washer and dryer. There was a locked storage cabinet containing cleaning supplies, detergents, and paper products.

LPA inspected the storage cabinet in the hallway and observed it containing clean linens and towels for residents’ use and found it well organized.

LPA toured the backyard area. The backyard has a shaded swing, a set of patio table and chairs. There were no bodies of water noted and was found clear of obstructions. The ramps in the front and backyard were found clear, without any tripping hazards.

LPA inspected the garage and observed a refrigerator containing additional food supplies and (2) treadmills for residents use under staff supervision.

LPA reviewed (4) staff personnel records and (4) resident records. The LPA observed that 4 of 4 residents 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 observed a locked centrally stored medication cabinet located inside the kitchen. 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. 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 reviewed Emergency Drill Logs and observed Emergency Disaster Drills were conducted every other month, with the most recent Earthquake drill completed on 12/15/2024.

Continued on 809-C

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

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