Routine inspection·November 6, 2025

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced annual required 1-year 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 Licensee Delores Davis 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 current. The following 12 Domains will be observed and reviewed: Infection Control, Physical Plant & Environmental Safety, Operational Requirements, Staffing, Personnel Records-Training, Client Rights-Information, Client Records-Incident Reports, Food Service, Health-Related Services, Incidental Medical Services, Disaster Preparedness, and Emergency Intervention. "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." The facility is a single-story family home located in a residential neighborhood. It features a living room, dining room, kitchen, 3 bedrooms, 1.5 bathrooms, an office area, a laundry room, an indoor/outdoor activity area, and a shaded area with outdoor patio furniture, tables, and chairs. Bedrooms #1-3 are designated as the resident's bedrooms. See continued LIC809-C page 2 Continued LIC809-C – Page 2 During the tour, LPA Bunker observed sanitizer, visitor log, and thermometer at the facility entrance. Logs of daily COVID-19 screening and temperature checks of clients and staff were available and updated. PPE supplies are readily available to staff, and an additional supply of PPE was observed. Sufficient liquid soap, paper goods, cleaning, and disinfecting supplies were observed. Documents are posted as mandated on the wall near the entryway’s sign-in sheet. The following Title 22-regulated areas were audited and found to be in compliance: • Telephones: Facility telephones are operational. • Bedrooms: All bedrooms meet the required standards for furniture, safety, privacy, and comfort. The facility maintains an adequate supply of linens. • Bathrooms: Bathrooms are clean and operational, providing necessary personal accommodations. Non-skid surface mats are in place to ensure safety and privacy. • Kitchen and Food Service: The kitchen is adequately equipped for food preparation and service. A review of the food supply confirmed an ample stock of perishable and nonperishable items, all stored appropriately. • Medication Storage and Management: Medications are centrally stored in a locked cabinet in the kitchen. Records are up to date, ensuring proper storage and documentation. • Common Areas: The living room, dining room, and other shared spaces are well-maintained, free of hazards, and meet cleanliness standards necessary for resident safety and well-being. • Safety Equipment and Measures: The facility is equipped with a fully stocked first aid kit and manual, functional smoke and carbon monoxide detectors, and properly charged fire extinguishers. Hot water temperature was measured at 120°F and remains within the standard range of 105–120°F. • Emergency Preparedness: All exit doors are in compliance. Client bedroom windows are equipped with sliding locks without thumbscrews. A fire drill was conducted on April 17, 2025. • Environmental Safety: The yard is free of 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 June 16, 2027. Compliance with HIV/TB requirements has been verified. There were no deficiencies were cited. LPA Bunker provided Licensee Delores Davis with a copy of the facility evaluation report. An exit interview was conducted.