COMMON AREAS: This includes the TV 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 11:20 a.m., hardwire combination of smoke and carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 11/03/2025. 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 is a functioning telephone on the premises. LPA observed surveillance cameras installed in the common areas of the facility however Administrator stated that all are inactive and will remain inactive.

INTERVIEWS: Starting at 10 a.m. and throughout the visit one (1) 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. LPA observed residents participating in the facilities music program. 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.

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. All 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 seven (7) total restrooms. One (1) is designated as a staff / guest restroom, six (6) are designated as a private resident restrooms. 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 109.5-115.5 degrees Fahrenheit, all within the required range. LPA observed storage space closets in hallway containing extra clean linens and towels for resident use.

LAUNDRY ROOM: LPA observed the locked laundry room adjacent to the main hallway. Laundry room has a washer and dryer and locked cleaning supplies.

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 110.5 degrees Fahrenheit. Cleaning supplies and other chemicals are kept in the locked laundry room and inaccessible to residents in care.

EXTERIOR: The exterior passageways were clean and clear of any obstructions. There is a covered patio area with tables and chairs for resident use located directly outside the sliding doors from the kitchen. There is a common recreational area with an additional covered patio area with furniture and a putting green for resident use. There were no bodies of water noted at the time of the visit. There is no front yard gate or driveway gate for the house individually, however the entire property is fenced. The garage is attached to the property. On 07/20/2026, the Licensee Representative submitted a notice, along with city permits, informing the Department that the facility will undergo construction in the garage to convert it into an additional dwelling unit (ADU). Report Continued on LIC 809-C PAGE 3...

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 06/29/2026 and are conducted quarterly. The emergency disaster plan and infection control plan were updated on 01/19/2026.

RECORDS: Resident Records: Six (6) 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 ; Active and in good standing.

MEDICATIONS: Medication review began at approximately 1:30 p.m. Medications are centrally stored and locked in a closet in the main hallway, adjacent to the living 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: LIC 500 facility roster, LIC 9020A Resident roster, copy of the Limited Liability insurance, and 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. Copy of report reviewed and provided.