Beginning at 10:39AM, the LPA, along with Facility Designee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

Hardwired smoke and carbon monoxide detectors were tested at 11:06AM and were functional at the time of the visit. Fire extinguisher was observed to be fully charged and purchased on 11/16/2023.

COMMON SPACES: The facility contains 2 (two) living rooms and 2 (two) dining areas. In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, both living rooms and both dining rooms furniture was observed to be in good condition. A fireplace was observed in each living room and both were adequately screened. Cleaning supplies were observed to be stored in a locked entry way closet. The LPA observed the required postings in the common area.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 6 (six) total bedrooms; 5 (five) bedrooms are for resident use and 1 (one) is designated as a staff room.

RESTROOMS: The LPA observed 3 (three) restrooms in the facility; 2 (two) are for shared use and 1 (one) is a private restroom. Restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in both common restrooms and initially measured slightly high, but was adjusted during the visit and subsequently measured within the required range.

Report Continued on LIC 809-C

OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for resident use. There are no bodies of water on facility premises. All exits and passageways were observed to be free of hazards. A locked detached garage was observed to contain extra food, emergency supplies, and storage.

RECORD REVIEW: Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 5 (five) resident records reviewed were complete and contained all required documents. 5 (five) staff files reviewed were complete and contained all required documents.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility’s infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually, as required. Emergency drills are conducted quarterly, with the last drill documented on 09/13/2023.

MEDICATION REVIEW: Medications for all residents are centrally stored locked and inaccessible to residents in care. Medications for 2 (two) residents were observed. Both 2 (two) of 2 (two) residents' medications were observed to be labeled and administered in compliance with regulation.

INTERVIEWS: Throughout the visit, LPA attempted to interview 2 (two) residents and 2 interviewed (two) staff.

No citations issued. Exit interview conducted. A copy of the report was provided.