At 8:50 AM, the LPA initiated a walk-through of the facility, accompanied by the administrator.

At 8:50 AM, the 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 stored medications were noticed.

At 8:56 AM, LPA inspected the family room, living room, and 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 in the dining area, and a set of couches, chairs, and tables in the living and the family room.

At 9:04 AM, LPA inspected the fire extinguisher mounted on the wall in the living room and found it was fully charged with a last service tag of 01/28/2024. 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 (3) bedrooms and (2) bathroom designated for residents' use, and (2) bedrooms designated for staff. All resident rooms are shared occupancy. At 9:08 AM, LPA inspected all (3) resident rooms and found them clean, well-lit, and equipped with the required furniture.

Continued on LIC 809-C

At 9:20 AM, LPA inspected the garage and found it clean. LPA observed a washer, dryer, refrigerator, freezer, pantry with dry food items, closets, and shelves with incontinence supplies.

At 9:24 AM, LPA toured the backyard area. The backyard has a covered patio with a set of a patio table and chairs for resident use. Chicken coop and basketball hoop were also seen. (3) locked storage sheds were inspected, containing incontinence supplies, luggage, and gardening tools. Ramps were observed in good condition with no blocking/tripping hazards. There were no bodies of water noted and was found clear of obstructions.

At 9:32 AM, the LPA inspected the first aid kit and observed it fully stocked.

At 9:36 AM, the LPA reviewed Emergency Drill Logs and observed drills are conducted every other month, with the most recent drill completed on 11/15/2024.

At 9:38 AM, The LPA reviewed (5) 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 5 of 5 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening, and confirmed that 5 of 5 staff members are associated with the facility.

At 10:00 AM, the LPA observed a locked centrally stored medication cabinet located in the main hallway, next to dining/kitchen. Medications were organized in separate bins for each resident. All medication bottles/bubble packs were properly labeled. Centrally Stored Medication Records (CSMR) were reviewed and found to be complete.

The following updated forms are requested to be submitted to CCLD by 12/11/2024:

• LIC 500: Personnel Report
• LIC 308: Designation of Facility Responsibility
• Certificate of Liability Insurance

• Surety Bond
• Administrator Certificate
• Lease Agreement

No deficiencies were cited during today's visit.

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