COMMON AREAS: This includes the family room, TV room, office and dining room. At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 1:10 p.m., hardwire combination of smoke, carbon monoxide detectors and fire doors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 02/17/2026, the facility also has an emergency fire blanket adjacent to the fire extinguisher. The emergency exiting plans/sketch are posted in every room. The emergency telephone numbers are posted in the common hallway. The LPA observed required postings throughout the common space. Activities were observed in the common areas. There are two (2) fireplaces in both living rooms that were adequately screened and non- functional. There is a functioning telephone on the premises. LPA observed surveillance cameras installed in the common areas of the facility. The staff presented the live monitoring screen located in the office to the LPA, confirming that all cameras were functioning properly and that none of them were equipped with audio capability. 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 10:03 a.m. one (1) staff, two (2) residents and one (1) visitor interviews were conducted. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident and visitor interview revealed that no concerns were noted or voiced at the time of the visit. Residents stated they enjoy the staff and feel safe in the home.

BEDROOMS: There are six (6) total bedrooms in the facility; all six (6) bedrooms are designated as private, single occupancy, resident rooms. There is no staff room and Administrator stated that staff remain awake at night. All resident rooms have exits to the exterior. All passageways were observed to be clear of obstructions. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

RESTROOMS: There are three (3) total restrooms. One (1) is designated as a shared / common resident restroom, and two (2) are designated as private resident restrooms. Resident restrooms were observed to be equipped with a slip resistant surface / mat. Grab bars were observed in all restrooms. The restrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in all resident restrooms and ranged between 109.3-115.1 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 109.8 degrees Fahrenheit. Cleaning supplies and other chemicals are kept in the laundry room locked and inaccessible to residents in care.

GARAGE: LPA observed the attached garage which is adjacent and accessible through the kitchen. The garage remains locked at all times. There is a laundry area containing a washer and dryer. There was a linen closet with extra towels and linens. Cleaning supplies and disinfectants are kept locked in the garage. LPA observed a staff break area. The LPA observed additional non-perishable food supply, emergency food and water, additional Personal Protection Equipment (PPE) and supplies. LPA observed an additional refrigerator containing extra food which was checked for proper labels and expiration dates.

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

RECORDS: Resident Records Five (5) 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. Personnel Records Five (5) 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 as of 01/11/2026. 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 6/18/26 and are conducted quarterly.

MEDICATIONS: Medication review began at approximately 12:35 p.m. Medications are centrally stored and locked in cabinets in the office, adjacent to the dining room. Medications for three (3) 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: Documents obtained during the visit include copies of the: LIC 500 facility roster, LIC 9020A Resident roster, Limited Liability insurance, Emergency disaster plan LIC 610E. At the time if the visit the LPA reviewed the facilities contact information on file including phone numbers, email and annual fees. Administrator confirmed that all information is accurate.

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