LPA and staff 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 facility is a single story house located in a residential neighborhood.

Report Continued on LIC 809-C PAGE 2...

• 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 10:05 a.m. and throughout the visit one (1) staff and one (1) resident interview were conducted. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interview revealed that no concerns were noted or voiced at the time of the visit. LPA attempted additional interviews however residents were observed to be sleeping.

BEDROOMS: There are seven (7) total bedrooms in the facility; four (4) bedrooms are designated as private, single occupancy, resident rooms, one (1) is designated as a shared, double occupancy, resident room and two (2) are designated as staff rooms. The staff rooms are kept locked at all times. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

RESTROOMS: There are six (6) total restrooms. Four (4) are designated as private resident restrooms, one (1) is designated as shared / common restrooms and one (1) is designated as a staff restroom. Resident restrooms were observed to be equipped with slip-resistant flooring. Grab bars were observed in the restrooms. The restrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in all resident restrooms and ranged between 106.2 - 110.5 degrees Fahrenheit, all within the required range.

KITCHEN: The LPA inspected the kitchen/food service area, Knives and sharps were observed in a locked drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 110.5 degrees Fahrenheit at 10:24 a.m. Cleaning supplies and other chemicals are kept in a locked cabinet under the sink inaccessible to residents in care.

BACKYARD: The entire property is fenced. The backyard has a portable umbrella for shade with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed two (2) self-latching gates. There were no bodies of water noted at the time of the visit. There are three (3) locked storage shed in the back yard inaccessible to residents.

Report Continued on LIC 809-C PAGE 3...

RECORDS: Two (2) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Pre- admission appraisal, LIC627(c) Consent for Treatment form, Home Health records, Hospice records, PRN authorization letters, and current needs and services plan. All records were in order. Three (3) Personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. At the time of the visit LPA conducted a business search to ensure the Business / LLC is in good standing. LLC is active and in good standing.

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 emergency disaster drill was reviewed on 06/04/2026 and the infection control plan was reviewed on 05/01/2026. 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 06/04/2026 and are conducted quarterly.

MEDICATIONS: Medications review began at approximately 11:15 a.m. The medications are stored adjacent to the kitchen, in the dining room, in locked cabinets. Medications for two (2) 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.

DOCUMENTS: LPA obtained the following documents during the visit: LIC 500 Facility roster, LIC 9020A Resident Roster, Current Liability Insurance and LIC 610E Emergency and Disaster Plan.

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