Beginning at 10:26AM, the LPA and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: Knives were observed in a locked drawer, cleaning supplies were locked and stored inaccessible in an under-sink cabinet. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food; all food was observed to be of good quality.

GARAGE: Adjacent to the facility kitchen is a locked garage. There is a laundry area where the washer and dryer are held, laundry supplies and cleaning supplies are kept locked. Resident personal care items were observed stored in the locked garage. There is a pantry with additional non-perishable food items and a refrigerator/freezer with additional perishable food items all food was observed be of good quality. There is a sufficient supply of emergency food and water kept in the garage.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature throughout the visit. Hardwired combination smoke and carbon monoxide detectors were tested at 11:49AM and were operational at the time of the visit. The two (2) fire extinguishers were fully charged and were last serviced 03/19/2024. The LPA observed the required postings throughout the common spaces. Auditory alarms were observed on all exit doors and functioned properly.

BEDROOMS: There are six (6) designated resident bedrooms and one (1) staff bedroom. All bedrooms were Report Continued on LIC 809-C

BATHROOMS: The five (5) resident bathrooms and one (1) visitor/staff bathroom were clean, sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature in resident bathrooms measured within the required range.

OUTDOOR AREA: The backyard has an outdoor area equipped with furniture and shade for resident use. There is a side gate for emergency exit and is single latched. No bodies of water noted.

RECORDS: 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.

Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order.

MEDICATIONS: Medications review began at 11:55AM; medications are centrally stored and locked in a closet in the kitchen to the right of refrigerator. Medications are labeled and checked for expiration dates, prescription numbers and date filled. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and updated annually as required. Emergency disaster drills are conducted quarterly with the last drill documented on 11/26/2024.