Beginning at 09:55AM, the LPA, along with Facility Designee 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:

BEDROOMS: There are five (5) bedrooms in the facility; four (4) bedrooms are designated for resident use, including two (2) shared rooms, and two (2) private rooms. There is one (1) staff room, which was observed to be locked. All four (4) resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

BATHROOMS: There are two (2) bathrooms for resident use, one (1) of which is a shared resident restroom located in the hallway and one (1) is a private resident restroom. Restrooms were observed to be equipped with slip-resistant surfaces. Grab bars were observed in the bathrooms. The water temperature was measured in the shared resident bathroom to be 115.5 degrees Fahrenheit, which is within the required range.

KITCHEN: The LPA observed the kitchen/dining area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food and emergency water. The LPA observed one designated cabinet where knives and sharps are stored Report 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.

LAUNDRY & GARAGE: The laundry room is located adjacent to the dining room. Laundry supplies and chemicals are stored in a locked cabinet, inaccessible to residents in care. Garage was observed locked and contained an additional freezer and pantry, which contained adequate emergency supplies.

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. Fireplace was noted to be screened and inaccessible to residents. The LPA observed the fire extinguisher to be fully charged and serviced on 12/19/2025. Hardwired smoke detectors and carbon monoxide detectors were tested at 10:03AM and were functional at the time of the visit. All required postings were observed in the facility entryway.

OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. Facility has two total gates, one (1) gate was observed to be self-latching and closing with clear passageways for emergency exit use. There were no bodies of water on the premises. An outdoor shed was observed to be locked.

RECORD REVIEW: Began at 10:11AM. Five (5) staff files and four (4) resident files 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 staff and resident records observed contained all required documents.

MEDICATION REVIEW: Began at 11:07AM. Medications for two (2) of four (4) residents were observed. Medications were observed to be stored in a locked cabinet in the kitchen island. Medication Administration Records (MAR) and Centrally Stored Medication and Destruction Records (CSMDR) were reviewed. All medications reviewed were properly documented and appear to be self-administered as prescribed.

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 drills are conducted quarterly; last emergency disaster drill was conducted 06/12/2026.

INTERVIEWS: LPA interviewed one (1) staff and two (2) residents. No concerns were noted.

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