Beginning at 10:39AM, the LPAs, along with 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:

Fire extinguisher was observed to be fully charged and last serviced 06/03/2024. Hardwired combination smoke/carbon monoxide detectors were tested at 11:51AM and were functional at the time of the visit.

BATHROOMS: There are (7) seven full bathrooms. There are (6) six private bathrooms for resident use, the full bathroom at the entrance of the home next to Room A (Staff Office) is designated for staff and guests. The showers are equipped with nonskid surfaces and available nonskid mats. Grab bars were observed in the bathrooms. Hot water temperature in bathrooms measured between 106.1 – 114.8 degrees Fahrenheit, which is within the required range.

BEDROOMS: There are (7) seven bedrooms in the facility; the facility has (6) six private bedrooms for resident use, and (1) one room that is used as a staff office and to store files. The staff office is kept locked. All resident rooms were observed and contain appropriate furnishings, linens, and adequate lighting.

LAUNDRY: The laundry area is in a locked laundry room located in the main hallway. Laundry detergent and cleaning supplies are stored inaccessible in the locked laundry room.

Report Continued on LIC 809-C

GARAGE: The garage was observed to be locked and contain storage, a refrigerator and freezer, both containing extra food.

COMMON AREA: The common areas were appropriately furnished and the lighting was adequate. There is a television and other entertainment equipment in the living room area. There is a functioning telephone on the premises. All required postings were observed on the entrance area wall. Emergency exiting plans/sketch are posted. Auditory alarms were observed on all exit doors. Various exit door alarms were tested and were functional at the time of the visit.

KITCHEN: Kitchen knives are stored locked and inaccessible in a drawer next to the stove. The supply of perishable and nonperishable food is adequate, as well as emergency food and water supply. Appliances in the kitchen were clean and appeared functional.

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 outside the front entrance. There are 3 (three) additional licensed facilities on the property. All 4 (four) facilities share a common recreation area with additional covered patio with furniture, a putting green, and bocce ball area for resident use. There are no bodies of water noted on the premises. There is no front yard gate and the driveway gate is kept unlocked.

RESIDENT & STAFF RECORDS: Beginning at 11:23AM (resident) and 12:10PM (staff), LPAs reviewed resident and staff files for but not limited to: physician's report, Admission Agreement, personal rights, staff health screening, TB test, background clearance, and training records. All 5 (five) of 5 (five) resident files reviewed and 5 (five) of 5 (five) staff files reviewed were observed to be complete and in compliance with Title 22 regulation.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPAs reviewed the facility's infection control plan and emergency disaster plan. The facility's policies as it pertains to infection control are adequate. The facility's emergency disaster plan was observed to be complete and updated annually, as required. Emergency disaster drills are conducted quarterly, with the last drill conducted on 07/21/2024.

Report Continued on LIC 809-C (p.3)

MEDICATIONS: Medications are stored in a medication closet located in the main hallway and is kept locked with a self-closing digital lock. The first aid supplies were complete, including a first aid manual. Medications were observed for 3 (three) residents. All 3 (three) of 3 (three) medications reviewed were stored and documented in compliance with regulation.

INTERVIEWS: Throughout today's visit, LPAs interviewed 4 (four) staff and 2 (two) residents. No concerns were noted.

During today's visit, LPAs obtained a copy of the following documents:

• liability insurance
• Personnel Report (LIC 500)