COMMON AREAS: This includes the living room, and dining room. At the time of the visit, furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. At 11:03 a.m. hardwire combination of smoke / carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 11/03/2025. The emergency exiting plans/sketch are posted in every room. The emergency telephone numbers are posted in the common hallway. The LPA observed required postings throughout the common space. Activities were observed in the common areas. At 11:00 a.m. LPA observed all five (5) residents to participate in music and dance enrichment. The fireplace in the living room was adequately screened. There is a functioning telephone on the premises. LPA observed surveillance cameras installed in the common areas of the facility and was informed by the Administrator that all the cameras are inactive and non-functional.

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MEDICATIONS: Medication review began at approximately 12:10 p.m. Medications are centrally stored and locked in a closet in the main hallway, adjacent to the kitchen. Medications for three (3) out of five (5) residents were reviewed. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. No errors observed during review.

LPA observed the first aid supplies to be complete, including sterile first aid dressings, bandages, tweezer, a thermometer and a current version of a first aid manual.

DOCUMENTS: Documents obtained during the visit include: LIC 500 facility roster, LIC 9020A Resident roster, copy of the Limited Liability insurance, and Emergency disaster plan (LIC 610E)

At the time if the visit the LPA reviewed the facilities contact information on file including phone numbers, email and annual fees. Administrator confirmed that all information is accurate.

No citations issued. Exit interview conducted. Copy of report reviewed and provided.

• 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.

INTERVIEWS: Starting at 10:20 a.m. and throughout the visit LPA conducted two (2) staff and two (2) resident interviews. Staff interviews revealed that staff are knowledgeable in Resident rights, different forms and signs of abuse, and reporting procedures. Resident interviews revealed that no concerns were noted or voiced at the time of the visit. Residents voiced being satisfied with the staff and facility.

BEDROOMS: There are seven (7) total bedrooms in the facility; six (6) bedrooms are designated as private, single occupancy, resident bedrooms and one (1) is designated as an office where files are stored. The office is kept locked. All rooms A-G have direct access to the outside. All passageways were observed to be clear of obstructions. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

RESTROOMS: There are seven (7) total restrooms. One (1) is designated as a staff / guest restroom, and six (6) are designated as private resident restrooms. Resident restrooms were observed to be equipped with a slip resistant surface / mat. Grab bars were observed in all restrooms. The restrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in all resident restrooms and ranged between 105.5-110.0 degrees Fahrenheit, all within the required range. LPA observed storage space closets in hallway containing extra clean linens and towels for resident use.

LAUNDRY: The laundry area is adjacent to the kitchen and kept locked at all times. Laundry detergent and other chemicals are stored in the laundry area inaccessible to residents in care.

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EXTERIOR: The exterior passageways were clean and clear of any obstructions. There is a covered patio area with tables and chairs for resident use located directly outside the sliding doors from the kitchen. There is a common recreational area with additional covered patio area with furniture and a mini golf area for resident use. There were no bodies of water noted at the time of the visit. There is a self-latching gate located on the side passageway. There is no front yard gate or driveway gate. The garage is attached to the property. On 07/20/2026, the Licensee Representative submitted a notice, along with city permits, informing the Department that the facility will undergo construction in the garage to convert it into an additional dwelling unit (ADU). The Administrator informed LPA that the construction work will not impact any resident common areas, bedrooms, bathrooms, or other interior or exterior spaces currently used by residents. Resident evacuation routes, room status, and fire clearance requirements will remain unaffected. The ADU will not be used by residents or have resident access and will be utilized by staff only. LPA was informed that construction is expected to begin within the next few weeks.

INFECTION CONTROL/ EMERGENCY DISASTER PLANNING: During today’s visit the LPA reviewed the facility’s infection control practices and the facilities emergency disaster plan. Both documents were observed to be complete and updated annually as required. The facilities policies and procedures, as they pertain to infection control and emergency planning meet the regulatory standard. The last emergency disaster drill took place on 06/29/2026 and are conducted quarterly. The emergency disaster drill was updated on 01/08/2026.

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