Routine inspection·September 16, 2025

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 11:30 a.m. Upon arrival, LPA Mosley was greeted by staff who called the Administrator to inform them of the visit. The Administrator / Licensee Representative, Molly Buck arrived shortly after and the reason for the visit was explained. Entrance interview. The LPA and staff / 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 living room, 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 1:52 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 12/31/2025. 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 08/13/2025 and are conducted quarterly. Activities were observed in the common areas. 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. INTERVIEWS : Starting at 11:38 a.m. two (2) staff and two (2) resident interviews were conducted. Staff interviews revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interviews 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... KITCHEN: The LPA inspected the kitchen/food service area at 11:50 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 111.1 degrees Fahrenheit at 11:52 a.m. Cleaning supplies and other chemicals are kept locked under the sink and inaccessible to residents in care. BEDROOMS: There are six (6) total bedrooms in the facility; all six (6) are designated as private, single occupancy, resident rooms. There is no staff room and Administrator stated that staff remain awake at night. Five (5) 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 restrooms, Two (2) are designated as a private resident restrooms. The facility also contains a separate shower room for resident use. 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 109.2-111.1 degrees Fahrenheit, all within the required range. LPA observed storage space closets in hallway containing extra clean linens and towels for resident use. GARAGE /LAUNDRY ROOM: LPA observed the locked garage /laundry room adjacent to the kitchen. Laundry room has a washer and dryer. LPA observed a sufficient supply of emergency food and water. LPA observed a staff / office area. Medications are stored in the locked cabinets inside the garage. LPA observed an extra refrigerator with food. Refrigerator was checked for proper labels and expiration dates. BACKYARD: The entire property is fenced. The backyard has a covered patio area with shade, patio furniture including tables and chairs for resident use. All passageways were observed to be clear. LPA observed one (1) self-latching gate. LPA observed a swimming pool that was properly fenced and locked at the time of the visit. Report Continued on LIC 809-C PAGE 3 ... (PAGE 3) Report Continued from LIC 809-C PAGE 2... MEDICATIONS: Medication review began at approximately 12:02 p.m. Medications are locked, centrally stored in cabinets located in the garage adjacent to the kitchen. 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. RECORDS: Resident Records w ere reviewed beginning at 1:05 p.m. Five (5) 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 2:03 p.m. six (6) 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. DOCUMENTS: Documents obtained during the visit include: LIC 500 - facility roster , LIC 9020A - Resident roster and 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 report reviewed and provided.