Beginning at 10:19AM, the LPA, along with Licensee Representatives began the physical plant tour to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

BEDROOMS: The LPA observed six (6) resident rooms, which were furnished appropriately with clean linens, furnishings, and sufficient lighting. The facility has one (1) staff room which remains locked and inaccessible to residents in care.

RESTROOMS: Resident bathrooms are clean and sanitary and in operating condition with grab bars and non-slip surfaces. The LPA observed two (2) bathrooms for resident use. Water temperature was measured in resident bathrooms and was observed to be within the required range.

KITCHEN: The LPA observed the kitchen/dining area to be clean and kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The LPA observed the kitchen refrigerator to be fully stocked at the time of visit. Knives and sharps are locked in a drawer next to the kitchen sink inaccessible to residents. Cleaning supplies are locked under the kitchen sink.

Report Continued on LIC 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.

GARAGE AND GROUNDS: The facility's garage is utilized as an office, staff break room, and storage space. Garage was observed to be locked and contained emergency food, water, and supplies as well as extra freezer and incontinence supplies. The LPA observed a covered patio area with patio furniture including a table and chairs for resident use. Facility has one (1) fence gate that self-latches with clear passageways for emergency exit use. There were no bodies of water accessible to residents at the time of visit.

MEDICATIONS: Medications review began at 10:45AM; medications are centrally stored and kept locked in a cabinet in the office/garage. Medications were observed for 2 (two) residents. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

RECORDS: Records review began at 11:10AM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. The facility's procedures as it pertains to infection control are adequate. Both documents were observed to be complete and updated annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 01/23/2025.

INTERVIEWS: During today's visit, LPA interviewed both staff and residents. No concerns were noted.

The LPA obtained the following documents: