Routine inspection·May 19, 2025

On May 19, 2025, the Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. The LPA met with the Administrator, Becky Bi, and disclosed the purpose of the inspection. The Administrator informed the LPA that the facility had (6) residents in care and (2) staff members present at the time. At 11:04 AM, the LPA initiated a walk-through of the facility, accompanied by the Administrator. LPA inspected the kitchen and found it clean, with lunch preparation and cooking in progress at the time. The appliances were checked and observed to be in working order. The LPA inspected a locked cabinet containing knives and sharp objects, detergents, disinfectants, and cleaning supplies. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No expired food items were noted. A locked box containing medications was observed. LPA inspected the dining area adjacent to the kitchen and found it clean. The dining table and chairs were observed to accommodate the residents, and all the furniture was in good repair. One (1) resident was observed sitting in the dining area. LPA inspected the living room and observed it clean, with all furniture in good repair. There were a sofa sets, coffee table, piano and a television in the living room. LPA inspected the fire extinguisher mounted on the wall in the dining area hallway and found it fully charged, with the last service tag dated 01/21/2025. Continued on LIC809-C The Administrator tested the smoke and carbon monoxide detector located in the living room in the LPA's presence, and it was found to be functional. Additional smoke and carbon monoxide detectors were observed in all bedrooms and common areas of the facility during the visit. There were six (6) bedrooms and six (6) bathrooms designated for residents' use. All (6) resident rooms were single occupancy. LPA inspected all (6) resident rooms and found them clean, well-lit, and equipped with the required furniture. Storage closets with incontinence supplies were observed in every room. LPA inspected six (6) full bathrooms and found them clean, sanitary, and in good working condition. The bathrooms contained soap, grab bars, paper towels, a trash can, a shower chair, and non-slip flooring. The hot water temperature at the sink faucet measured 113.7°F and 115.1°F. The hallway closets were observed to contain clean linens and towels for residents’ use. LPA inspected the locked garage located behind the house in the backyard and observed a washer, a dryer, mattresses, suitcases, and furniture items. LPA toured the backyard area and found ramps and passageways in good condition, clear of obstructions, with no blocking or tripping hazards. The backyard has a set of a patio table, chairs, and shaded areas for resident use. No bodies of water were noted. LPA reviewed five (5) staff personnel records and (5) resident records. The LPA observed that 5 of 5 residents had an Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, and CSDMR. LPA observed that 5 of 5 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that staff members were associated with the facility. LPA observed a locked centrally stored medication cabinet inside the dining area. Medications were organized in separate bins for each resident. All medication bottles were properly labeled. Centrally Stored Medication Records were reviewed and found to be complete. LPA inspected the first aid kit and found it fully stocked. Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster Drills were conducted quarterly, with the most recent drill completed on 03/19/2025. Continued on LIC809-C The following updated forms are requested to be submitted to CCLD by 05/26/2025: LIC 500: Personnel Report LIC 308: Designation of Facility Responsibility Certificate of Liability Insurance Administrator Certificate(s) No deficiencies were cited during today's visit. An exit interview was conducted with the Administrator. A copy of this report was left with the Administrator, Becky Bi, whose signature on this form confirms receipt of the report.