Routine inspection·July 31, 2025

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Required - 1 Year Annual visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the evaluation, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms, and temperature was checked. LPA Bunker met with Licensee/Administrator Angela Love and explained the purpose of today's annual inspection. LPA verified that the facility has an approved Mitigation Plan Report and Infection Control Report. There are currently six (6) residents in placement. The facility's annual fees are up to date. The following 12 Domains will be observed and reviewed: Infection Control, Operational Requirements, Physical Plant & Environmental Safety, Staffing, Personnel Records-Training/Staff Training, Resident Rights-Information, Planned Activities, Food Service, Incidental Medical and Dental, Resident Records/Incident Reports, Disaster Preparedness, and Resident with Special Health Needs. "LPA Bunker will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections." Ms. Love and LPA Bunker toured the facility, which is a single-story family home located in a residential neighborhood. The house consists of a living room, family room, dining room, kitchen, office, 5 bedrooms, 2 bathrooms, laundry room, detached garage, an indoor/outdoor activity area, and a shaded area furnished with outdoor patio furniture, including tables and chairs. Bedrooms #1 through #5 are designated as the resident's bedrooms. See continued LIC809-C page 2 Continued LIC 809-C page #2 LPA Bunker observed the facility’s infection control practices, including screening protocols for residents and visitors, hand sanitizer, a visitor log, and a thermometer in the facility's living room. Logs documenting daily COVID-19 screening and temperature checks of clients and staff were available and up to date. PPE supplies are readily available to staff, and an additional supply of Personal Protective Equipment (PPE) was observed. Sufficient quantities of liquid soap, paper goods, cleaning, and disinfecting supplies were observed. Documents are posted as mandated on the wall in the living room, family room, and the hallway. The following Title 22-regulated areas were audited and found to be in compliance: The facility telephones are working. Bedrooms: All bedrooms meet the required standards for furniture, safety, privacy, and comfort. The facility has an adequate linen supply. Bathrooms: The bathrooms are clean and operational, and provide necessary personal accommodations with non-slip surface mats ensuring safety and privacy. Kitchen and Food Service: The kitchen is adequately equipped for food preparation and service. A review of the food service revealed an ample supply of perishable and nonperishable food, stored appropriately. Medication Storage and Management: Medications are centrally stored in a locked cabinet in the office with up-to-date records, ensuring proper storage and documentation. Common Areas: The Living room, dining room, and common areas are well-maintained, free of potential hazards, and meet the cleanliness standards necessary for the safety and well-being of residents. Safety Equipment and Measures: The facility is equipped with a fully stocked first aid kit with manual, functional smoke and carbon monoxide detectors, and a properly charged fire extinguisher. The hot water temperature is measured at 105 and 108.5 degrees and is maintained within the standard range of 105-120 degrees Fahrenheit. Emergency Preparedness: All exit doors are in compliance, the client's bedroom windows are equipped with sliding window locks without thumbscrews, and the facility conducted a fire drill on May 15, 2025. Environmental Safety: The yard is free from debris and hazards, trash cans are covered, and no firearms or bodies of water are present on the premises. Hazardous items are kept inaccessible to clients. Staff Training: Staff members have received training on dependent adult and elder abuse reporting. Administrative Compliance: The Administrator's Certificate is current, with an expiration date of August 26, 2025. Compliance with HIV/TB requirements is also verified. LPA Bunker provided Licensee/Administrator Angela Love with a copy of the facility evaluation reports. There were no deficiencies cited. An exit interview was conducted.