At 9:20 AM, the LPA initiated a walk-through of the facility, accompanied by the administrator.

At 9:22 AM, the LPA inspected the kitchen and found it clean, with no food preparation or cooking in progress at the time. A bottle of dish washing soap was observed placed on the sink. The LPA checked the appliances and observed them in working order. The 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 9:30 AM, the LPA observed knifes and scissor kept in an unlocked kitchen cabinet and accessible to residents in care. LPA observed Comet bleach and Clorox disinfectant wipes in a closet underneath the kitchen sink and accessible to residents in care.

At 9:38 AM, 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. The LPA inspected the fire extinguisher mounted on the wall and found it was fully charged with last a service tag of 02/06/2024. 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

There are (6) bedrooms and (5) bathrooms designated for residents' use, (2) bedrooms and (1 1/2) bathrooms designated for staff, and (1) office room. All resident rooms are single occupancy. Resident bedrooms #1, #2, #4 and #5 have private bathrooms. At 9:48 AM, LPA inspected all (6) resident rooms and found them clean, well-lit, and equipped with the required furniture.

At 10:04 AM, LPA inspected the common resident bathroom 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. The hot water temperature at the sink faucet was measured at 112.1°F. At 10:12 AM, the LPA inspected the hallway half bathroom and observed it in clean, sanitary, and operating condition. The hot water temperature at the sink faucet was measured at 110.6°F.

At 10:16 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 10:20 AM, LPA inspected the garage and observed a washer, dryer, refrigerator, and freezer. The garage was observed cluttered with boxes, Incontinence supplies, furniture, food supplies, and mattresses.

At 10:26 AM, LPA toured the backyard area. The backyard has a set of patio table, chairs, and umbrella for resident use. There were no bodies of water noted and was found clear of obstructions.

At 10:38 AM, the LPA inspected the office, staff bedrooms, and staff bathroom and found them clean.

At 10:53 AM, The LPA reviewed (4) staff personnel records and (6) resident records. The LPA reviewed that 2 of 6 residents records didn’t contain Physician's Reports. LPA reviewed that 2 of 4 staff members didn’t have LIC 503 Health Screening. LPA reviewed that 1 of 4 staff members is not associated with the facility.

At 11:07 AM, the LPA observed a locked centrally stored medication cabinet located inside the staff/administrator room. Medications were organized in separate bins for each resident. All medication bottles were properly labeled. Centrally Stored Medication Record (CSMR) were reviewed and found to be complete.

Continued on LIC 809-C

At 11:20 AM, the LPA reviewed Emergency Drill Logs and observed Emergency Disaster Drills were not conducted quarterly, with the most recent drill completed on 1/07/2024.

The following updated forms are requested to be submitted to CCLD by 12/03/2024:

• 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 Licensee. A copy of this report and appeal rights were discussed and left with the Administrator, Becky Bi, whose signature on this form confirms receipt of these documents.