Kitchen: The kitchen/food area was observed at 9:25 a.m. The facility does not contain a full kitchen, only a kitchenette. The kitchenette consists of pantry and dry food storage area and a refrigerator. As such, the facility does not contain 7-day supply of perishable and 2-day supply of non-perishable foods. Staff indicated that the facility food for lunch and dinner is stored and prepared off-site. Breakfast is prepared in the kitchenette and snacks are available throughout the day for clients.

Common Areas: Furniture was observed to be in good condition, and the lighting was adequate. The facility maintained a comfortable temperature. The LPA observed the required postings in the common area. The smoke detector(s) and carbon monoxide detector were operational at the time of the visit. The fire extinguisher was observed to be fully charged on 11/21/2023. There is a functioning telephone on the premises. The LPA observed the fireplace in the living room adequately screened. The last fire inspection was completed on 11/21/2023 and was found to be in compliance with Fire Code Regulations at the time of inspection. Fire and earthquake drills conducted within the last 6 months as per regulation; the last one conducted 09/15/2023.

(Report Continued on LIC 809C...)

Restrooms: The three (3) client restrooms were clean and 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 was measured in all three (3) bathrooms and measured between 105- and 120-degrees Fahrenheit.

Bedrooms: There are three (3) double occupancy client bedrooms. All three (3) bedrooms were furnished with appropriate linens and required furniture. Adequate lighting in all bedrooms was observed.

Records: The LPA reviewed client records at 9:54 a.m. and staff records at 10:58 a.m. and the LPA reviewed three (3) client files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan. All client files were in order.

The LPA reviewed five (5) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid certification and yearly training. All files were complete.

The LPA conducted interviews with two (2) staff and three (3) clients between 1:09 p.m. and 2:10 p.m.

Medications: Medications review began at approximately 10:15 a.m.; medications are centrally stored and locked inside the Medication Room. All medications including PRNs were labeled, stored, and locked inaccessible to clients. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during medications review.

No deficiencies were noted at this time. Exit interview conducted. Report was reviewed and a copy was issued.