The LPA and 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.

COMMON AREAS: This includes the living room, open office area 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 11:56 a.m., hardwire combination of smoke / carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 06/24/2026. The emergency exiting plans/sketch are posted. 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. The fireplace in the living room was adequately screened. There is a functioning telephone on the premises. LPA observed surveillance cameras installed in the common areas of the facility. The Administrator / Licensee representative presented the live monitoring screen to the LPA, confirming that all cameras were functioning properly and that none of them were equipped with audio capability.

INTERVIEWS: Starting at 9:40 a.m. and throughout the visit one (1) staff and two (2) resident, and one (1) family visitor interviews were conducted. Staff interview revealed that staff is knowledgeable in Resident rights, different forms of abuse, and reporting procedures. 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.

Resident interviews revealed that no concerns were noted or voiced at the time of the visit. Family visitor interview revealed that "They are pleased with the quality of care that is provided by the staff".

BEDROOMS: There are seven (7) total bedrooms in the facility; Six (6) bedrooms are designated as private, single occupancy, resident rooms and one (1) staff room. The staff room is kept locked at all times and observed to be occupied by staff. Six (6) of six (6) 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 four (4) total restrooms. Two (2) are designated as a shared / common resident restrooms, One (1) is designated as a private resident restroom, One (1) is designated as a staff restroom. Resident restrooms were observed to be equipped with a slip resistant surface / mat. 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 116.8-120 degrees Fahrenheit, all within the required range. LPA advised the Administrator to monitor the water temperature since the water was at the maximum and reviewed the regulatory standard of 105-120. LPA observed storage space closets in hallway containing extra clean linens and towels for resident use.

GARAGE: LPA observed the facility garage, which was locked and contained emergency food and water, a storage room containing emergency supplies, an extra refrigerator/freezer that were checked for proper labels and expiration dates.

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 118.6 degrees Fahrenheit. Cleaning supplies and other chemicals are kept in the locked supply closet adjacent to the kitchen and garage entrance.

LAUNDRY AREA: LPA observed an open laundry area adjacent to the kitchen, and locked supply closet. Laundry area has a washer and dryer. Laundry supplies are kept locked in the supply closet adjacent to the washer and dryer. Report Continued on LIC 809-C PAGE 3...

RECORDS: Resident Records were reviewed beginning at 10:54 a.m. Six (6) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, Hospice records, Home Health records, PRN authorization letters and current needs and services plan. All records were in order. Personnel Records : Four (4) 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.

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. Both documents were reviewed on 01/28/2026. 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 06/24/26 and are conducted quarterly. Administrator stated they have a drill scheduled for the end of the month.

MEDICATIONS: Medication review began at approximately 12:30 p.m. Medications are centrally stored and locked in cabinets in the kitchen 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. LPA observed the first aid supplies to be complete, including sterile first aid dressings, bandages, tweezer, a thermometer and a current version of a first aid manual.

DOCUMENTS: Documents obtained during the visit include: LIC 500 facility roster and LIC 9020A Resident roster, copy of the Limited Liability insurance, 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. Copy of report reviewed and provided.