COMMON SPACES/ BACKYARD: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture appear to be in good condition. The fire extinguishers appeared to be fully charged and were last inspected 04/02/2025. The smoke and carbon monoxide detectors were tested throughout the tour and functioned properly. Activities were observed in the common areas. There is a washer and dryer on the premises. Laundry soap is stored in a locked cabinet. The fireplace in the living room was adequately fenced. The facility has a sufficient supply of emergency food and water located in the supply room and garage. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. There were no bodies of water noted at the time of the visit.

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

BEDROOMS: There are four (4) client bedrooms; two (2) are designated as private, single occupancy bedrooms and two (2) are designated as a shared double-occupancy bedroom. LPA observed all client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

MEDICATIONS: Medication audit was conducted for two clients. The medications are locked in a cabinet adjacent to the kitchen in a medication box. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. The LPA observed inconsistencies in the Centrally Store Medication and Destruction Record (CSMDR) that is pre documented and filled by the Pharmacy and the labels on the clients medication bubble packs that is also noted by the pharmacy. LPA advised the House Manager to either filled out their own CSMDR, or review the CSMDR provided by the pharmacy as well as contacting the pharmacy and obtain information on the inconsistencies.

RECORDS: A record review was conducted. The LPA reviewed documentation of infection control plan, emergency disaster plan and emergency disaster drill took place on 10/28/2025 and conducted quarterly. Four out of four client files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All files were in order at the time of the visit. P&I money was reviewed for all clients, cash resources were found to be separate and intact and not commingled with facility funds or petty cash.

INTERVIEWS: One client interview was conducted. No concerns were voiced.

Due to time constraints the LPA will complete the annual at a later date.

During today’s visit, the LPA obtained copies of the following: Staff roster, LIC 9020 Resident Roster, and Insurance Liability.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.