A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit:

Physical Plant & Environment Safety: The facility is a 2-story residence, two shared client bedrooms are on the 1^st floor, there is one restroom on the 1^st floor for client use. Second floor was toured by LPA, the second floor contains 2 offices, one staff bedroom, one room used for storage, and one staff restroom. The stairs have a door that is kept lock to prevent clients access. Facility currently occupies 4 clients. LPA toured client rooms and observed that rooms were tidy, the lighting and lamps are sufficient for the use of the facility and for client comfort and safety. Toilet, hand washing and bathing facilities are operational. The pathways are clear of any obstructions. The facility has sufficient space inside and outside for activities and visiting. The facility has internet service for client use and each client has their own device to use. The fire extinguisher was last charged and inspected on 1/7/26. The facility has carbon monoxide and smoke detectors which were tested during the visit and working. Hot water temperature was measured within regulation temperatures 105-120*(f). Cleaning supplies are inaccessible to clients in care, kept locked under kitchen cabinet and in the garage.

Operational Requirements: Facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity of 4. Fire clearance is granted for 4 ambulatory clients. Surety Bond expires 7/1/26.

Continued on 809-C

• 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.

Client Records & Incident Reports: The facility keeps separate files on each client confidentially. Facility does submit incident reports to the department when required. LPA reviewed 4 client files for signed Admission Agreements, Physician reports, and IPPs. All forms were legible.

Food Service: The facility has 2-day perishables and 7-day non-perishables to meet the food service requirements. All food is covered, stored, and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies. Kitchen area and appliances are clean and maintained. LPA observed fresh fruit and a variety of snacks available for clients.

Incidental Medical Services: Facility provides transportation or assists in providing transportation to medical and dental appointments when needed. The facility uses the Centrally Stored Medication and Destruct Records (CSMDR) and Medication Administration Record (MAR). LPA reviewed a sampling of clients’ medications, no medications were expired, and all medications were kept in their original containers. All medication was documented.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts monthly fire drills and quarterly disaster drills. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency.

Exit interview conducted and copy of report printed.