At 9:10 AM, the LPA initiated a walk-through of the facility, accompanied by the manager.

There are (2) floors with (8) bedrooms on the 1^st floor and (11) bedrooms on the 2^nd floor. All resident rooms are single occupancy with vanity and a bathroom without shower area. At 9:14 AM, LPA inspected random 3 resident rooms on the 1^st floor and 6 resident rooms on the 2^nd floor, and found them clean, well-lit, and equipped with the required furniture.

At 9:26 AM, LPA measured hot water temperatures in random rooms. The hot water temperature at the sink faucet was measured at 151.7°F in room #6 and 136.3°F in room #7 on the 1^st floor, and 162.5°F in room #10 and 142.6°F in room #14 on the 2^nd floor.

At 9:42 AM, the LPA inspected the hallway half bathroom and observed it in clean, sanitary, and operating condition. At 9:46 AM, the LPA inspected the common resident bathroom with shower and found it clean, sanitary, and in good working condition. It contained soap, grab bars, a trash can, non-slip flooring, and a shower chair.

At 9:52 AM, the LPA inspected the storage space in the hallway and observed it containing clean linens for residents’ use and found it well organized.

At 9:54 AM, LPA inspected the laundry room and observed a washer and dryer in working condition. The elevator was found in operational condition.

At 9:58 AM, LPA inspected the dining area and observed it clean, with all the furniture in good repair.

Continued on LIC 809-C

At 10:13 AM, the LPA inspected the fire extinguishers mounted on the hallway wall (on both 1^st and 2^nd floors) and found they were fully charged with a last service tag of 08/07/2024. The manager tested the smoke and carbon monoxide detector located in the hallway in the LPA's presence, and it was found to be functional.

At 10:20 AM, LPA inspected the basement and observed pantry storage area, water heaters and other storage supplies. At 10:26 AM, LPA toured the backyard area and observed patio tables, chairs, and an umbrella for resident use. There were no bodies of water noted and was found clear of obstructions/tripping hazards.

At 10.38 AM, the LPA observed a locked centrally stored medication cabinet located inside the med 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. The LPA inspected the first aid kit and observed it fully stocked.

At 10:53 AM, The LPA reviewed (4) staff personnel records and (5) resident records. The LPA observed that 5 of 5 clients 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 11:20 AM, the LPA reviewed Emergency Drill Logs and observed Emergency Disaster Drills were not conducted quarterly.

The following updated forms are requested to be submitted to CCLD by 12/09/2024:

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

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