Beginning at 09:22AM, the LPA, along with Licensee/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. The following was observed:

Hardwired smoke detectors and separate carbon monoxide detector were tested at 11:43AM. All were functional at the time of the visit. Fire extinguisher was observed to be fully charged and last serviced on 01/08/2024.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

Adjacent to the kitchen is the locked facility garage, which contains chemical storage, extra food supply, as well as storage. Licensee was advised to obtain additional supply of emergency water.

BEDROOMS: There are 5 (five) total bedrooms, of which 2 (two) are designated for private resident use and 2 (two) are designated for shared use, and 1 (one) is a locked staff room. The LPA observed all resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: The LPA observed 2 (two) restrooms in the facility; 1 (one) is for shared use and 1 (one) is designated for private resident use. Resident restrooms were observed to be clean and sanitary and in

Report Continued on LIC 809-C

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the facility entryway. An adequately screened fireplace was observed in the living room.

OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for resident use. All exits and passageways were observed to be free of hazards.

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 Admission Agreements. 5 (five) resident records were reviewed; all 5 (five) resident files contained these required documents. 5 (five) staff files reviewed were complete and contained all required documents.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility’s infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually, as required. Emergency drills are conducted quarterly, with the last drill documented on 01/03/2024.

MEDICATION REVIEW: Medications for 2 (two) residents were observed. Both 2 (two) of 2 (two) residents' medications were observed to be maintained and administered in compliance with regulation. First aid kit was observed to be complete.

INTERVIEWS: Throughout the visit, LPA interviewed 2 (two) residents and 2 (two) staff.

No citations issued. Exit interview conducted. A copy of the report was provided.