Routine inspection·September 25, 2025

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 10:30 a.m. Upon arrival, LPA Mosley was greeted by staff who called the Administrator to inform them of the visit. Administrative staff Manju Natarajan arrived shortly after and the reason for the visit was explained. Entrance interview. The LPA and staff 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 two (2) living rooms rooms, 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 2:40 p.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 10/03/2024. The emergency exiting plans/sketch are posted. 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 05/24/2025. LPA advised staff that drills are to be conducted quarterly and was informed that a drill will be conducted this week. Activities were observed in the common areas. The fireplace in the living room was adequately screened. There is a functioning telephone on the premises. LPA observed surveillance cameras installed in the common areas of the facility. The staff 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. INTERVIEWS : Starting at 10:36 a.m. one (1) staff and two (2) resident interviews were conducted. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interview revealed that no concerns were noted or voiced at the time of the visit. Report Continued on LIC 809-C PAGE 2 ... (PAGE 2) Report Continued from LIC 809-C... BEDROOMS: There are eight (8) total bedrooms in the facility; six (6) bedrooms are designated as private, single occupancy, resident rooms and two (2) staff rooms. The staff rooms are kept locked at all times and observed to be occupied by staff. One (1) out of six (6) 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 four (4) total restrooms. Two (2) are designated as a shared / common resident restroom, and two (2) are designated as a private resident restrooms. Resident restrooms were observed to be equipped with a slip resistant surface / mat. Grab bars were observed in the restrooms. The restrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in all resident restrooms and ranged between 108.6-114.3 degrees Fahrenheit, all within the required range. LPA observed storage space closets in hallway containing extra clean linens and towels for resident use. KITCHEN: The LPA inspected the kitchen/food service area at 10:54 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. The kitchen faucet was measured for hot water temperature, and it measured 118.6 degrees Fahrenheit at 10:55 a.m. Cleaning supplies and other chemicals are kept under the sink locked and inaccessible to residents in care. LAUNDRY ROOM: LPA observed the locked laundry room adjacent to the garage. Laundry room has a washer and dryer and locked cleaning supplies. 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. Only 1 (one) pathway is used as an emergency exit which was free of obstructions at the time of the visit. RECORDS: Resident Records were reviewed beginning at 11:01 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, Home Health records, PRN authorization, hospice records and current needs and services plan. All records were in order. Report Continued on LIC 809-C PAGE3 ... (PAGE 3) Report Continued from LIC 809-C PAGE 2... Personnel Records were reviewed beginning at 12:03 p.m. Five (5) 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. The facilities policies and procedures, as they pertain to infection control and emergency planning, meet the regulatory standard. MEDICATIONS: The first aid supplies were complete, including a first aid manual. Medication review began at approximately 2:23 p.m. Medications are centrally stored and locked in a closet adjacent to the living room and 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 copy of the Limited Liability insurance. During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. Exit interview conducted. Copy of report reviewed and provided.