Beginning at 10:37 a.m., the LPA 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:

BEDROOMS: The facility is a single-story residential home with six (6) private, single occupancy resident bedrooms. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

RESTROOMS: There are three (3) restrooms of which two (2) are designated for private resident use and one (1) is a shared, common use. Restrooms were clean and sanitary and in operating condition with grab bars and slip resistant surfaces. The restrooms were sufficiently stocked with liquid hand soap and paper towels; towels and washcloths are not shared. The hot water temperature was measured in all restrooms and measured within the required range.

LAUNDRY ROOM: LPA observed the locked laundry room with a washer and dryer. Cleaning supplies and detergents were observed locked and inaccessible at the time of the visit.

BACKYARD: The backyard has an area equipped with outdoor furniture including a table and chairs for resident use with appropriate shade. Facility has an in-ground pool, which was observed to be fenced with

Report Continued on LIC 809-C

• 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.

COMMON AREAS: 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 01:16 p.m., hardwired combination smoke and carbon monoxide detectors were tested and were operational at the time of the visit. The three (3) fire extinguishers were observed to be fully charged and last serviced on 05/15/2026. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 05/11/2026 and are conducted quarterly. Activities were observed in the common areas. The facility has a working telephone on the premises. Auditory alarms on all doors were functional at the time of the visit. Entry/exits were free of obstruction.

KITCHEN: Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Food labels were inspected and checked for dates and expiration. The knives and sharps were observed in a locked drawer inaccessible. Cleaning supplies were observed to be locked under the kitchen sink. Medications are stored in locked kitchen cabinets.

GARAGE: The garage was observed locked and inaccessible to residents at the time of the visit. The facility has a sufficient supply of emergency food and water which was observed to be in good condition. LPA observed a freezer in the garage, the food was inspected for dates and food labels that had expiration dates clearly marked. The garage also contains a seating/rest area for staff.

RECORDS: Records review began at 11:10 a.m., five (5) resident records were reviewed for, but not limited to: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, current needs and services plan, and hospice records. All records were in order. Five (5) personnel records, 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 files were in order.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, LPA reviewed the facility’s infection control practices and emergency disaster plan. The facility's policies and procedures as they pertain to infection control and emergency preparedness are satisfactory.

INTERVIEWS: One (1) staff and two (2) resident interviews were conducted during the inspection. No concerns were noted or voiced at the time of the visit.

DOCUMENTS: Documents obtained during the visit include: LIC 500 personnel roster, LIC 610E and current liability Insurance.

No deficiencies cited. Exit interview conducted. A copy of the report was reviewed and issued.