Beginning at 09:42AM, the LPA, along with Licensee 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 combination smoke and carbon monoxide detectors were tested at 10:53AM and were functional at the time of the visit. Fire extinguishers were observed to be fully charged and purchased on 04/22/2023.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. Adjacent to the kitchen is a locked garage. The garage was observed and contained the laundry area, as well as emergency food supply and water, and storage.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 4 (four) total bedrooms for resident use; 2 (two) are shared rooms and 2 (two) are private rooms.

RESTROOMS: The LPA observed 2 (two) restrooms in the facility. 1 (one) is for resident use and 1 (one) is designated for staff use. Resident restroom was observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in the resident restroom and initially measured high, but was adjusted and subsequently measured within the required range.

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. Report Continued on LIC 809-C

OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for resident use. All exits were observed to be clear 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 personal rights. 5 (five) resident records reviewed were complete and contained all 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 10/01/2023.

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.

INTERVIEWS: Throughout the visit, LPA interviewed 2 (two) staff and 1 (one) resident.

During today's visit, LPA gathered the following items:

• LIC 500
• A copy of the facility's liability insurance