COMMON AREAS: This includes the living room, 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 12:00 p.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 03/15/2026. 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 living room had an electric fireplace that is not utilized. 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 to the LPA, confirming that all cameras were functioning properly and that none of them were equipped with audio capability.

INTERVIEWS: Starting at approx. 10 a.m. three (3) staff and two (2) resident interviews were conducted. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interviews revealed that no concerns were noted or voiced at the time of the visit. 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.

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 117.1 degrees Fahrenheit. Cleaning supplies and other chemicals are kept locked under the sink inaccessible to residents in care.

LAUNDRY: The facility has an open concept laundry room / area adjacent to kitchen with machines that were in good condition. Laundry detergent and facility cleaning supplies were stored locked in a cabinet located in the laundry area.

BEDROOMS: There are nine (9) bedrooms in the facility; the facility has (6) six private bedrooms for resident use, and (2) two staff break rooms rooms, and one (1) storage room. Both staff break rooms are kept locked at all times and observed to be utilized by staff with a couch, chairs and television. The storage room was observed to be empty with a hoyer lift at the time of the visit. Staff stated that it is utilized for storage and for the hoyer lift. Bedrooms #1, #3, #5, and #6 have direct exits to the exterior with all bedrooms cleared for a total of six (6) bedridden residents. Lighting in the rooms appeared adequate. All resident rooms were observed and were furnished appropriately, with clean linens appropriate furnishings and sufficient lighting. During last years visit it was determined that the facility’s floor plan provided to CCL did not match the current floor plan and a citation and civil penalty were assessed. During todays visit the administrative staff informed the LPA they are actively working with the city to ensure compliance, and have contacted the architect they are in communication with to provide LPA with an update regarding the status.

BATHROOMS: There were four (4) total restrooms in the facility: two (2) private resident restrooms and two (2) common area restrooms. Restrooms were clean, sanitary, and in operating condition with grab bars and slip resistant surfaces. All restrooms were sufficiently stocked with soap, paper products, and displayed hand washing signs. Hot water was tested and measured between 110.0 117.1 degrees F. All within the required range.

GARAGE: LPA observed the attached garage which is accessible through the living room, which was locked at the time of the visit. The LPA observed two (2) rooms in the garage that were used as storage at the time of the visit containing boxes, and extra furniture. Report Continued on LIC 809-C page 3

EXTERIOR: The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the backyard with tables and chairs for resident use. There is a gated pool that was observed to be locked and inaccessible. The back and sides of the house are separated from the front yard by gates at the north and south-side passageways, both gates have self-latching mechanisms.

RECORDS: Resident Records were reviewed beginning at approx. 10:48 a.m. Five (5) 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, 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.

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 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 9/24/26 and are conducted quarterly.

MEDICATIONS: 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. Medication review began at approximately 1:10 p.m. Medications are centrally stored and locked in a cabinet located in the kitchen. 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: LIC 500 facility roster, LIC 9020A Resident roster, copy of the Limited Liability insurance, LIC 610E Emergency disaster plan. 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 at this time. Exit interview conducted. Copy of report reviewed and provided.