The LPA and Administrator 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.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a temperature of 77 degrees Fahrenheit. At 11:13 A.M., hardwire combination of smoke/carbon monoxide detector and fire doors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 06/27/2026. The emergency telephone numbers are posted in common hallway. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 07/05/2026 and are conducted quarterly. Activities were observed in the common areas. The fireplace in the living room was adequately screened. LPA observed a locked storage closet adjacent to the entrance with an adequate amount of emergency supplies. There is a functioning telephone on the premises. The LPA observed cameras in all common spaces and exterior. LPA observed that one resident was using supplemental oxygen; however, "No Smoking – Oxygen in Use" signage was not present in areas where oxygen was in use. Technical Violation (TV) issued. Administrator immediately posted signs in the appropriate locations throughout the facility.

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.

BATHROOMS: There are three (3) bathrooms. Two (2) are designated as shared/common bathroom, one (1) is designated as a private resident bathroom in Room #2. Resident bathrooms were observed to be equipped with a slip-resistant surfaces and grab bars. The restrooms were sufficiently stocked with supplies and paper towels. The water temperature was measured in all restrooms and ranged between 107.2 - 109.6 degrees Fahrenheit, all within the required range.

GARAGE: The entry to the garage was observed to be locked and inaccessible to residents. The garage was observed to contain a washer and dryer, laundry supplies and chemicals and various cleaning supplies. Garage contained adequate emergency water supplies. LPA observed an extra refrigerator with food that was checked for proper labels and expiration dates.

KITCHEN: The LPA inspected the kitchen/food service area at 10:10 A.M. Knives and sharps were observed in a locked drawer. 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 108.3 degrees Fahrenheit at 10:13 A.M. Cleaning supplies and other chemicals are kept in a locked cabinet inaccessible to residents in care.

Continued on LIC 809-C

RECORDS: Record review began at approx. 10:52 A.M. 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. Six (6) 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 LPA Conway reviewed the facility’s infection control practices and emergency disaster plan. The facilities policies and procedures as they pertain to infection control and emergency preparedness are satisfactory, however, they were last reviewed/updated more than 12 months ago. Technical Violation (TV) issued.

MEDICATIONS: Medications review began at approximately 1:15 p.m. The medications are in a locked cabinet area adjacent to the kitchen. Medications for three (3) of five (5) residents were reviewed. 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 two complete first aid kits, one located in the kitchen and the other one located in the medication cabinet.

The following documents were obtained during today’s visit: Personnel Report (LIC 500), Register of Facility Residents (LIC 9020), and current Liability Insurance. LPA observed that the facility sketch on file did not accurately reflect the current layout of the facility. LPA requested an updated sketch to be submitted to the Department.

No citations issued. Exit interview conducted. Copy of the report provided