Non-compliance follow-up·August 12, 2025

At 9:28am, on 8/12/2025, Licensing Program Analyst (LPA) Haner-Tomasko conducted an unannounced Case Management - Legal/Non-Compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance as discussed in the Non-Compliance Conference that took place on 07/01/2025. As a result of the non-compliance conference, the licensee is placed on frequent monitoring for a period of two years. LPA met with Lead Staff Kevin Schaefer and explained the reason for the visit. The LPA focused today’s visit on ensuring there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. At 9:35am, LPA and Lead Staff Kevin Schaefer conducted a walk through of the facilities first floor where residents reside, the second floor is only accessed by facility staff. LPA observed four (4) residents were in chairs in the family room watching TV and the fifth resident was in bed in their room. Resident rooms were observed to be furnished appropriately with sufficient lighting. Resident bathrooms were sufficiently stocked with supplies and paper towels. At 9:48am LPA observed an aerosol can of Raid bug spray and a can of Pledge furniture cleaner sitting out on bookshelves in the family room accessible to residents and at 9:52am an aerosol can of Favor furniture cleaner and Clorox disinfectant mist left out in the living room next to the TV accessible to residents in care. This facility fire clearance allows for a bedridden resident in bedroom #3. LPA interview revealed Resident #1 (R1) requires assistance from staff with turning or repositioning, meaning R1 meets the bedridden definition in Title 22 Regulations for this facility type and R1 does not reside in bedroom #3. The facility has battery operated smoke detectors in each bedroom and the hallway leading to bedrooms that are all working, the carbon monoxide detector is in the hallway and functioning normally. (Continued on LIC809-C) LPA observed multiple fire extinguishers throughout the facility in the green compression range, Kevin stated none of them have been serviced or purchased in the last year. Fire clearance violations were cited. At 10:16am LPA tested facility hot water in the resident shower which reached a maximum of 97.9*(f), not within regulation temperatures of 105*-120*(f). LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods. LPA noted a previous deficiency on 11/18/2024 when the Licensee was unable to show documentation of emergency drills conducted. The Licensee submitted documentation clearing the plan of correction for that deficiency on 12/04/2024. As of todays visit staff interview revealed an emergency drill has not been conducted this year. LPA spoke with the Licensee over the phone as they could not be at the facility in person. Exit interview, deficiencies cited on LIC809-D pages, a civil penalty in the amount of $500 for fire clearance violations is being assessed on the LIC421IM, a civil penalty in the amount of $250 for a repeat violation is being assessed on the LIC421FC, report signed, report and appeal rights provided to Backup Administrator.