At 09:40AM, the LPA along with staff 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:

KITCHEN: The LPA observed the kitchen / food area at approximately 9:50AM. The kitchen was observed to be clean, and appliances appeared to be in operable condition. The facility has a sufficient supply non-perishable and perishable food; properly stored. Refrigerator and dry food pantry were checked for proper labels and expiration dates. Cleaning supplies are stored locked and inaccessible under the kitchen sink. Knives and other sharps were observed to be locked inside the staff’s office.

BEDROOMS: There are three (3) client bedrooms located in the second floor. Client bedrooms are designated for double occupancy. The LPA observed all client bedrooms to be properly furnished with sufficient lighting. The bedrooms had appropriate and adequate bedding and linens. The LPA observed a locked closet with client’s personal hygiene items.

Report Continued on LIC 809C...

• 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.

COMMON AREAS: In the first floor, there is a therapy room, counselor’s office, dining room, and living room. The common areas were furnished appropriately, and all furniture was observed to be in good condition. There is a fireplace in the living room, which was observed to be adequately screened. In the second floor, there is a second therapy room and learning lab with computers and internet for client use. The Offices are kept inaccessible to clients unless properly supervised. No obstructions or hazards were observed inside or out.

LAUNDRY ROOM: The laundry room is located on the first floor. Clients have a designated laundry day and are responsible for their own laundry needs. Detergents and cleaning supplies were observed in locked cabinets inside the laundry room.

OUTDOOR AREAS: The front yard includes a driveway, paved walkways and landscaped areas. The backyard is fenced and includes both paved and landscaped areas. There is a shaded patio area with furniture appropriate for outdoor use. The LPA observed an in-ground pool which was locked and inaccessible to clients at the time of the visit. Facility staff indicated clients sometimes use the pool, when properly supervised. The LPA also observed a basketball court, stable, and locked barn. There are two (2) gates that self-latch for emergency use. The exterior passageways were clean and clear of any obstructions.

Report Continued on LIC 809C...

Five (5) client files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, Needs & Service Plans, and treatment/rehabilitation plan. All client files were in order.

Four (4) staff files were reviewed for, but not limited to, the following: personnel records, health screening, criminal record statements, cpi training, and current first aid certification and yearly training. All files were complete.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. There are several fire extinguishers throughout the facility; they were fully charged and were last serviced 02/24/2025. Carbon monoxide detectors are wired and operational at the time of the visit. The last fire safety inspection was completed on 08/13/2024 and sprinkler system inspection on 11/2024; both were found to be in compliance with Fire Code Regulations at the time of inspections. Emergency disaster drills conducted quarterly as per regulation; the last one conducted 06/19/2025. Daily vehicle inspection list, current registration, and insurance was reviewed for facility vehicles.

MEDICATION REVIEW: The LPA conducted a medication review at approximately 12:20PM. Medications are centrally stored in a medication room on the first floor. The medication room has adequate locked storage, as well as a locked refrigerator. Medications were properly labeled and appeared to be given as prescribed. The 1st Aid Kit was observed to be complete inside the medication room.

No citations issued. Exit interview conducted. Report was reviewed and a copy was issued.