Beginning at 09:24 a.m., the LPA along with the 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:

Common Areas: This includes the living room and dining room areas. Furniture in the common areas was observed to be in good condition at the time of the visit. The facility maintained a comfortable temperature. The LPA observed a fireplace in the living room; adequately covered. The LPA observed activity supplies in the common areas accessible to residents in care. The LPA observed a fire extinguisher to be fully charged with a purchase date of 03/08/2026. Required postings were observed throughout the common space. There is a working telephone on premises. First aid kit was observed complete at the time of the visit. No hazards/obstructions observed inside or out.

Restrooms: There are two (2) restrooms for resident use. Bathrooms were clean and fixtures were in operating condition. Showers had non-skid surfaces and grab bars. The bathrooms were sufficiently stocked with all necessary supplies.

Report Continued on LIC 809C...

Four (4) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, consent for treatment form, preplacement appraisals, appraisals, and current needs and services plan. All files were in order.

Five (5) personnel files were reviewed for, but not limited to: personnel record, health assessment with negative TB test results, criminal record clearance, first aid/CPR training, and the appropriate yearly training. All personnel files were complete. The Administrator’s certificate is valid until 10/07/2026.

Medications: The LPA conducted a medication review at approximately 12:00 p.m. Medications are centrally stored and kept in a locked closet adjacent to the living room. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications were properly documented on the centrally stored medication & destruction record (CSMDR) at the time of the visit. Medications appear to be administered as prescribed at the time of the visit.

Emergency Disaster Planning: During today’s visit, the LPA reviewed the facility's infection control plan and emergency disaster plan, which were observed to be complete and recently reviewed/updated. Emergency disaster drills conducted quarterly as per regulation; last disaster drill conducted on 07/02/2026.

No citations issued at this time. Exit interview conducted. A copy of the report was issued.

Bedrooms: There are three (3) bedrooms for resident use. Bedrooms are designated as shared / double occupancy. Bedrooms were observed to be furnished appropriately and had sufficient lighting. Additional clean linens and towels were observed in a closet by the hallway. There is no staff bedroom on premises. 24-hour awake staff.

Kitchen: The LPA inspected the kitchen/food service area at approximately 09:35 a.m. Knives and sharps were observed under the sink locked and inaccessible to residents in care. Cleaning supplies were observed locked and inaccessible under the kitchen sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. At 09:40 a.m., the hot water temperature was measured in the kitchen sink at it measured at 110.7 degrees Fahrenheit.

Garage: The garage is attached to the house and was locked at the time of the visit. Washer and dryer were observed inside the garage. Detergents and cleaning supplies were observed locked and inaccessible to residents in care at the time of the visit. The LPA observed an adequate amount of emergency food and water.

Backyard: The backyard has a shaded area with adequate furniture for resident use. Emergency passageway was observed to be clear of any obstructions. There is a side gate with latching mechanisms for emergency purposes. The LPA observed a locked shed for storing purposes. No bodies of water noted at the time of the visit.

Report Continued on LIC 809C...

• 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.