Routine inspection·September 11, 2025

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 10:00 a.m. Upon arrival, LPA Mosley was greeted by staff who called the Administrator to inform them of the visit. The Administrator / Licensee Representative, David Flood arrived shortly after and the reason for the visit was explained. Entrance interview. The LPA and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. COMMON AREAS: This includes the family room, TV room, office 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 10:25 a.m., hardwire combination of smoke, carbon monoxide detectors and fire doors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 08/27/2025. 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. The last emergency disaster drill took place on 06/06/2025 and are conducted quarterly. Activities were observed in the common areas. There are two (2) fireplaces in both living rooms that were adequately screened and non- functional. There is a functioning telephone on the premises. LPA observed surveillance cameras installed in the common areas of the facility. The Administrator presented the live monitoring screen to the LPA, confirming that all cameras were functioning properly and that none of them were equipped with audio capability. Report Continued on LIC 809-C PAGE 2 ... (PAGE 2) Report Continued from LIC 809-C... INTERVIEWS : Starting at 10:19 a.m. two (2) staff, two (2) residents and one (1) visitor interviews were conducted. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident and visitor interview revealed that no concerns were noted or voiced at the time of the visit. BEDROOMS: There are six (6) total bedrooms in the facility; all six (6) bedrooms are designated as private, single occupancy, resident rooms. There is no staff room and Administrator stated that staff remain awake at night. All 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 three (3) total restrooms. One (1) is designated as a shared / common resident restroom, and two (2) are designated as private resident restrooms. Resident restrooms were observed to be equipped with a slip resistant surface / mat. Grab bars were observed in all restrooms. The restrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in all resident restrooms and ranged between 114.3-115.1 degrees Fahrenheit, all within the required range. KITCHEN: The LPA inspected the kitchen/food service area at 10:44 a.m. 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. LPA observed a locked medication box in the refrigerator with medication. The kitchen faucet was measured for hot water temperature, and it measured 114.6 degrees Fahrenheit at 10:45 a.m. Cleaning supplies and other chemicals are kept in the laundry room locked and inaccessible to residents in care. GARAGE: LPA observed the attached, locked, garage adjacent and accessible through the kitchen. There is a laundry area containing a washer and dryer. There was a linen closet with extra towels and linens. Cleaning supplies and disinfectants are kept locked in the garage. LPA observed a staff break area. The LPA observed additional non-perishable food supply, emergency food and water, additional Personal Protection Equipment (PPE) and supplies. LPA observed an additional refrigerator containing extra food which was checked for proper labels and expiration dates. Report Continued on LIC 809-C PAGE 3 ... (PAGE 3) Report Continued from LIC 809-C PAGE 2... BACKYARD: The entire property is fenced. The backyard has a covered patio area with shade, patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed one (1) self-latching gate. There were no bodies of water noted at the time of the visit. There is a locked storage shed in the back yard inaccessible to residents. Pathways used as emergency exits were free of obstructions at the time of the visit. RECORDS: Resident Records : were reviewed beginning at 10:55 a.m. Six (6) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, PRN authorization letters, Home Health records and current needs and services plan. All records were in order. Personnel Records were reviewed beginning at 11:53 a.m. four (4) 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. 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. MEDICATIONS: Medication review began at approximately 1:20 p.m. Medications are centrally stored and locked in cabinets in the office, adjacent to the dining 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 and a copy of the current Limited Liability insurance. During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. Exit interview conducted. Copy of the report reviewed and provided.