Routine inspection·June 5, 2025

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 12:58PM. LPA initially met with facility staff. Licensee/Administrator was contacted via telephone and arrived at the facility at 01:07PM. Entrance interview conducted. Beginning at 01:14PM, the LPA, along with Licensee 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. The following was observed: RESTROOMS: The LPA observed 2 (two) restrooms in the facility; one is a shared restroom and one is a private restroom. Resident restrooms are clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. Water temperature was measured in both resident restrooms and measured within the required range. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 (five) total bedrooms; 4 (four) are designated for private resident use and 1 (one) is designated as a shared resident room. There is an additional staff rest area off the dining room, which was observed to contain a bed and sliding glass door exit. LPA noted this area is on the facility sketch submitted for the 07/20/2024 fire clearance. GARAGE: The garage was observed adjacent to the facility kitchen. Garage remains locked. The garage contains laundry area, emergency food and water, as well as supplies and extra food. KITCHEN : Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and Report Continued on LIC 809-C properly stored at the time of the visit. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. A fireplace was observed to be adequately screened. Fire extinguishers were observed to be fully charged and last serviced on 06/15/2024. Licensee stated annual service is scheduled. Hardwired combination smoke and carbon monoxide detector were tested at 04:00PM and were functional at the time of the visit. Auditory alarms on exit doors were observed to be functional. OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. There is one exit gate. All pathways and exit routes were observed to be unobstructed. RECORD REVIEW: Began at 01:35PM, staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 5 (five) resident records reviewed were complete and contained all required documents. 5 (five) staff files reviewed were complete and contained all required documents. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility’s infection control practices. The facility’s policies and procedures as it pertains to infection control are adequate. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually as required. INTERVIEWS: Throughout the visit, LPA interviewed various staff and residents. No concerns were noted. MEDICATION REVIEW: Began at 03:47PM. Medications for 2 (two) residents were observed. Both 2 (two) of 2 (two) residents' medications were observed to be maintained, administered, and documented in compliance with regulation. No citations issued. Exit interview conducted. A copy of today's report was provided.