LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. The smoke alarms and carbon monoxide detectors were tested and function properly. LPA observed one (1) fire extinguisher to be new and fully charged on 08/04/2024.

There is two (2) double occupancy bedrooms and two (2) single occupancy bedrooms for resident use and one (1) staff room. Each bedroom is equipped with clean mattresses, pillows, and bedding. Bedrooms have sufficient lighting. There is a cabinet in the hallway with a sufficient supply of linens, including blankets, bath towels and wash cloths. There is a locked closet with the resident’s personal hygiene items. The facility has two (2) bathrooms for resident use. Resident bathrooms contained appropriate non-skid mats and grab bars. Bathrooms have sufficient paper products. Hot water temperature was measured in both bathrooms, and they measured between 105- and 120 degrees Fahrenheit. LPA observed trash cans with tight fitting lids at the time of the visit.

LPA toured the kitchen area at 10:10 a.m. The facility has at least seven (7) day supply of non-perishable food and two (2) days perishable food. Appliances and all equipment appear to be clean and in good repair. Kitchen knives and sharps were observed in a locked drawer next to the gas range. The kitchen has a sufficient supply of plates, cups, cookware, and utensils.

Report Continued on LIC 809C...

Medications are stored and locked in a file cabinet adjacent to the dining room. Facility records and First aid kit was by the medications. First aid kit was observed to have bandages, thermometer, scissors, tweezers and a current first aid manual. Facility has an adequate 30-day supply of Personal Protection Equipment (PPE).

The garage is attached to the house and inaccessible to residents in care. There is one (1) additional refrigerator in the garage with extra food for resident use. The washer and dryer was observed inside the garage. Detergents, disinfectants, and cleaning supplies are stored locked and inaccessible. There will be no firearms/ammunition stored on the property. There is a sufficient supply of emergency food and water.

The facility has required postings, including emergency exit plan, Licensing Complaint Poster, Resident Personal Rights, Theft and Loss Policy, and Resident Council Rights.

The exterior passageways were clean and clear of any obstructions. There is one (1) self-latching gate for emergency use. There are no bodies of water on the premises at the time of the visit. LPA observed the backyard, which has a covered outdoor area with a table and chairs for resident use.

Comp III conducted with Applicant Representative.

Physical plant is NOT accurate with the submitted facility sketch / floor plan. There are five (5) rooms total. Sketch submitted only shows four (4) bedrooms. Fire clearance only approved for four (4) bedrooms.

Report Continued on LIC 809C...

· Submit a new facility sketch / floor plan and obtain fire clearance for additional rooms.

Exit interview conducted. The report was reviewed, and a copy was provided.