Beginning at 11:59AM, the LPA, along with Assistant Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

Fire extinguisher is fully charged and purchased on 03/21/2023. Hardwired combination smoke and carbon monoxide detectors were tested at 01:46PM and all were functional at the time of the visit. No fire clearance concerns were observed.

KITCHEN: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. Cleaning supplies are located in a locked cabinet under the kitchen sink. Knives are stored in a locked drawer.

COMMON AREAS: This includes the living room and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. An adequately screened fireplace was noted in the living room. Locked laundry room was observed. All required postings were observed in the common area.

GARAGE: Garage was observed and contained extra food, PPE and incontinence supplies, and emergency food and water.

BEDROOMS: There are seven (7) total bedrooms in the facility; six (6) bedrooms are designated for resident use and one (1) staff room. The staff room is kept locked. All resident rooms were observed to be furnished

Report Continued on LIC 809-C

BATHROOMS: There are three (3) bathrooms for resident use. One (1) is designated for shared resident use and two (2) are private restrooms. Restrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed in the bathrooms. The water temperature was measured in the shared resident bathroom and measured in compliance with regulation.

OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. There were no bodies of water on the premises.

RECORD REVIEW: Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. All four (4) staff files and five (5) resident files observed were in compliance with regulation. Administrator Certificate was observed to be expired, however LPA reviewed the Administrator Certification website, which indicated all documents were received and the Administrator's Certificate is still pending at this time. All trainings were observed to be complete.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly, with the last drill conducted on 09/30/2023. Emergency disaster plan was observed to be complete and updated annually, as required.

MEDICATION REVIEW: Began at 01:35PM. Medications for two (2) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit.

INTERVIEWS: During today's visit, LPA attempted to interview two (2) staff and two (2) residents.

No deficiencies cited. Exit interview conducted. A copy of today's report was provided.