At 9:16 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, and a locked cabinet next to the sink with detergents, disinfectants, and cleaning supplies. 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.

LPA inspected the fire extinguisher mounted on the wall in the dining area and found it fully charged, with the last service tag dated 11/08/2024. The Administrator tested the smoke and carbon monoxide detector located in the kitchen area 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 living room and observed it clean, with all furniture in good repair. There were sofa sets, chairs, a coffee table, a piano, and a television in the living room. (1) resident was observed watching TV. Video cameras were observed in the living room, dining area, and other common areas of the facility, for which the Administrator had obtained signed acknowledgment document from the resident/authorized representative.

Continued on LIC809-C

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

LPA inspected the garage and found it clean. A washer, a dryer, a refrigerator, a freezer containing additional food supplies, and storage racks shelves with non-perishable food items, incontinence supplies, and paper products were observed.

LPA toured the backyard area and found ramps and passageways in good condition, clear of obstructions, with no blocking or tripping hazards. The backyard has a set of a patio table, chairs, and shaded areas for resident use. No bodies of water and no tripping hazards were noted. LPA inspected (1) storage shed and observed wheelchairs, furniture items, outdoor furniture, and gardening products stored in the shed.

LPA reviewed (6) 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 6 of 6 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 6 of 6 staff members were associated with the facility.

LPA observed a locked centrally stored medication cabinet inside the dining area. Medications were organized in separate bins for each resident. All medication bottles were properly labeled. 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 12/18/2024.

Continued on LIC809-C

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

No deficiencies were cited during today's visit.

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