Beginning at 10:43 AM, the LPA, along with facility Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer which contained knives and other sharp objects. LPA observed two (2) secured cabinets which contained resident medications. Additionally, LPA observed the kitchen to contain sufficient emergency food supplies, the facility’s washer and dryer, and the facility’s first aid kit. LPA observed a camera in the kitchen area and confirmed with the Administrator that audio is not recorded.

GARAGE: LPA observed the garage to be inaccessible to clients in care. The garage was observed to contain cleaning supplies, extra care supplies, emergency water supplies, and an extra refrigerator.

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.

BEDROOMS: There are five (5) bedrooms in the facility; one (1) is a dual occupancy room and four (4) are single occupancy rooms. LPA and facility Administrator toured all five (5) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedrooms #4 & 5 contain direct exits to the outdoors of the facility. LPA observed a RING camera with an auditory recording component installed in bedroom #1. LPA informed the Administrator that residents shall have the personal right to have a reasonable level of personal privacy in accommodations. LPA informed the Administrator that due to the camera’s auditory recording component, no admission agreement addendum regarding video surveillance, no mention of video surveillance in private areas of the facility in the facility's plan of operation, and no approved waiver for video surveillance in private areas of the facility on file with the department that the camera would need to be removed from the resident’s room. The Administrator informed LPA that the camera was installed at the resident’s family member’s request. The Administrator removed the camera from the resident’s room immediately and agreed to complete an admission agreement addendum, to submit a waiver request to the department, and to update the facility’s plan of operation prior to the installation of any future cameras in private areas of the facility.

BATHROOMS: There are four (4) bathrooms at the facility. Three (3) bathrooms are designated as private resident bathrooms, and one (1) bathroom is designated as a shared resident bathroom. All resident bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near resident toilets, all were properly secured. LPA observed the shared resident bathroom to contain appropriately secured cabinets which contained personal grooming supplies for resident use. The water temperature was measured between 111.2 and 114.4 degrees Fahrenheit, which is in compliance with regulation.

Continued on LIC 809C.

RECORD REVIEW: Record review began at approximately 11:20 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Three (3) staff files were reviewed. All staff files contained all required documents and trainings. Six (6) resident files were reviewed all resident files contained all required documentation and signatures. No deficiencies were observed during record review.

MEDICATION REVIEW: Medication review began at 01:22 PM. Medications for three (3) of six (6) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 07/22/2026. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator.

INTERVIEWS: LPA interviewed two (2) residents and two (2) staff members. Both residents interviewed stated that the staff treat them well and are attentive to their needs. Both residents had no concerns with the facility. Both staff interviews were conducted with the assistance of the facility Administrator acting as a translator. Both staff members interviewed understood their roles and responsibilities, the resident’s rights, the different forms of abuse, and the appropriate reporting procedures for suspected abuse.

During today’s visit LPA obtained a copy of the facility’s updated emergency disaster plan, LIC 500, resident roster, and liability insurance. The following deficiency was cited (Refer to LIC 809D). Exit interview conducted and a copy of the report and appeal rights were provided.