COMMON AREAS: This includes the living room, and dining room. At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 12:48 p.m., hardwire combination of smoke / carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 05/20/2025. The emergency exiting plans/sketch are posted. The emergency telephone numbers are posted in the common hallway. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 10/20/2025 and are conducted quarterly. Activities were observed in the common areas. The fireplace in the living room was adequately screened and noted to be non-functional. There is a functioning telephone on the premises.

INTERVIEWS: Starting at 9:28 a.m. and throughout the visit two (2) staff and two (2) resident interviews were conducted. Staff interviews revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interviews revealed that no concerns were noted or voiced at the time of the visit.

Report Continued on LIC 809-C PAGE 2...

• 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 six (6) total bedrooms in the facility; four (4) bedrooms are designated as private, single occupancy, resident rooms, one (1) shared, double occupancy resident room and one (1) staff rooms. The staff rooms are kept locked at all times and observed to be occupied by staff. Two (2) out of five (5) resident rooms have exits to the exterior. All passageways were observed to be clear of obstructions. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

RESTROOMS: There are two (2) total restrooms. One (1) is designated as a shared / common resident restroom, One (1) is designated as a private resident restroom. Resident restrooms were observed to be equipped with a slip resistant surface / mat. Grab bars were observed in the restrooms. The restrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in all resident restrooms and ranged between 105.6-116.1 degrees Fahrenheit, all within the required range. LPA observed storage space closets in the hallway containing extra clean linens and towels for resident use.

KITCHEN: The LPA inspected the kitchen/food service area. Knives and sharps were observed in a locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 118.6 degrees Fahrenheit. Cleaning supplies and other chemicals are kept in the garage locked and inaccessible to residents in care.

GARAGE: LPA observed the attached facility garage accessible through the kitchen, which was locked at the time of the visit. LPA observed emergency food and water, personal protection equipment (PPE) , incontinent supplies, laundry units including washer, dryer and detergent, an extra refrigerator and freezer that were checked for proper labels and expiration dates.

BACKYARD: The entire property is fenced. The backyard has a covered patio area with shade, patio furniture including a table and chairs for resident use. LPA observed one (1) self-latching gate. There were no bodies of water noted at the time of the visit. Only one (1) pathway is used as an emergency exit which was free of obstructions at the time of the visit.

Report Continued on LIC 809-C PAGE 3...

RECORDS: Resident Records: Five (5) Resident 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 records were in order.

Personnel Records Five (5) Personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

INFECTION CONTROL/ EMERGENCY DISASTER PLANNING: During today’s visit the LPA reviewed the facility’s infection control practices and the facilities emergency disaster plan. Both documents were observed to be complete and updated annually as required. The facilities policies and procedures, as they pertain to infection control and emergency planning meet the regulatory standard.

MEDICATIONS: Medication review began at approximately 2:05 p.m. Medications are centrally stored and locked in a cabinet in the kitchen adjacent to the dining room. Medications for Three (3) residents were reviewed. Medications were properly documented on the centrally stored medications and destruction record. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self administered as prescribed and documented on the centrally stored medication and destruction records. No errors observed during review. LPA observed the first aid supplies to be complete, including sterile first aid dressings, bandages, tweezer, a thermometer and a current version of a first aid manual.

DOCUMENTS: Documents obtained during the visit include: LIC 500 facility roster and LIC 9020A Resident roster and copy of the Limited Liability insurance.

During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. Exit interview conducted. Copy of report reviewed and provided.