Bob & Corky's Care Home IV

Type of visit: Required - 1 Year

At 01:30pm, on 4/30/2026, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct the annual facility inspection. LPA met with Backup Administrator - Shawna Harney, announced who he was and the reason for the visit. Backup Administrator and LPA conducted a full tour of the facility. This facility is a single-story residential home with five resident bedrooms (one is dual occupancy) and three full bathrooms all for public/shared use. There is a living room, dining room, kitchen and activities/office area. The living room has a fireplace with barrier for resident safety. Access to the laundry room and both garages are through locked doors for resident safety. LPA noted that the backyard and the front yard both have seating and shade for residents and visitors. The facility has battery operated smoke detectors in each room that are all working, the carbon monoxide detector is in the hallway and functioning normally. LPA observed a fire extinguisher in the kitchen that was tagged current and in the green compression range, serviced on 3/9/2026. LPA tested facility hot water at 110.8°F, within regulation temperatures 105-120°F. LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods. LPA noted that the facility is clean and in good repair with no obstructions in hallways, doorways or exits. Medications are locked in cabinets in the kitchen and garage. LPA conducted a sample medication audit and reviewed the facilities Centrally Stored Medication Records, finding no violations. LPA conducted a staff and resident file review. LPA and backup Administrator conducted a review of the annual care tool modules. No citations given at this time. Exit interview conducted, report signed, and report provided to the backup Administrator.the state’s words, verbatim · CDSS document, Apr 30, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Garrett Haner-Tomasko conducted a case management – incident visit to the facility along with personnel from Tri-Counties Regional Center (TCRC). LPA met with Administrator Deborah Cole and explained the purpose of the visit. The Department received an incident report regarding a resident found on the ground in the backyard of the facility by staff. The Department also received photos of injuries that occurred to the resident’s face, elbow, knee and toes possibly due to this incident. During the visit, LPA and TCRC personnel checked on the resident’s wellness and toured the facility. Staff are not sure how the resident got outside, the resident was last checked at 3:40am in their room and at approximately 6:50am during shift change the resident was found outside in the backyard. Staff check on residents approximately every two hours throughout the night and state this resident does often ask staff to leave their room when they do their checks. After the incident, staff implemented additional precautions for the resident’s safety; placing a floor mat with alarm next to the bed and a pressure bed alarm to alert staff of the residents attempt to get out of bed without assistance between staff checks, conducting extra checks on the resident, and a meeting was conducted between TCRC personnel, the facility administrator and residents responsible person to discuss additional safety measures. The resident states they like this facility and the staff that care for them. They do not recall falling recently. LPA and TCRC personnel provided technical assistance to the facility administrator and licensee on reporting requirements and additional safety measures that can be taken to keep the resident safe. During this visit no deficiencies were cited, but the LPA may return at a later date if citations are warranted. Exit interview conducted, report signed, and report provided to the Administrator.the state’s words, verbatim · CDSS document, Jan 26, 2026

Type of visit: Required - 1 Year

At 01:30pm, on 03/24/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct the annual facility inspection. LPA met with Backup Administrator - Shawna Harney, announced who he was and the reason for the visit. At 1:50pm Backup Administrator and LPA conducted a full tour of the facility. This facility has five resident bedrooms (one is dual occupancy), three full bathrooms all for public/shared use. There is a living room, dining room, kitchen and office area. Access to the laundry room and both garages are through locked doors for resident safety. LPA noted that the backyard and the front yard both have seating and shade for residents and visitors. LPA observed residents actively involved in a craft activity at the time of the visit. The facility has battery operated smoke detectors in each room that are all working, the carbon monoxide detector is in the hallway and functioning normally. LPA observed a fire extinguisher in the kitchen that was tagged current and in the green compression range, serviced on 03/21/2025. LPA tested facility hot water at 109.8*(f), within regulation temperatures 105*-120* (f). LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods. LPA noted that the facility is clean and in good repair with no obstructions in hallways, doorways or exits. Medications are locked in cabinets in the kitchen and garage. LPA conducted a sample medication audit and reviewed the facilities Centrally Stored Medication Records, finding no violations. LPA conducted a staff and resident file review. LPA and Backup Administrator conducted a review of the annual care tool modules. No citations given at this time. Exit interview, report signed, and report provided.the state’s words, verbatim · CDSS document, May 8, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Miller arrived at 8:25 am to conduct a 1-year annual visit to the facility above. LPA met with Administrator Joel Wobrock, and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs are visible. The facility has EPA approved disinfectant spray and cleaners. The facility has a 30-day supply of PPE stored in house 2. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). Trash cans and wastebaskets have tight fitting covers. Physical Plant & Environment Safety: The fire extinguisher was last charged and inspected on April 4, 2024. The facility has 5 resident bedrooms, and 3 bathrooms. LPA was authorized to enter and inspect facility. The facility has a smoke and carbon monoxide detector that was tested and working properly during visit. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. During the tour of the facility LPA found kitchen knives, disinfectants and cleaning solutions under kitchen sink that were accessible to residents in care. The items were quickly removed and Administrator advised that maintenance will repair the lock on the cabinet under kitchen sink. Continued 809-C The facility has sufficient space inside and outside for activities and visiting. The facility has a secured backyard and front patio for client use with plenty of shade. The facility has telephone and internet service for resident use. Operational Requirements: The facility has a current plan of operation on file with the department. The facility has current liability insurance and expires on April 19, 2025. The Facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity of 6. The fire clearance is granted for 6 non-Ambulatory, 1 of which may be bedridden. Hospice is approved for 4. Staffing: The facility currently employes 7 full time staff, and 2 Administrators. Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance and education requirements. Administrator Certificate expires October 26, 2024. Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours for 2023 and 2024. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for signed Admission Agreements, Safeguard for property and valuables, LIC. 602A Physicians report, Appraisals Needs and Services Plan, Emergency and ID forms. Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables and plenty extra, to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies. Continued 809-C Incidental Medical Services: Facility provides assistance in arranging transportation to medical and dental appointments when needed. Residents have on-call doctor that visits facility. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed residents’ medications, no labels were altered, no medications were expired and all medications were kept in their original containers. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. Emergency exits and telephone numbers were posted. A set of keys is available upon request through the licensee for staff on all shifts to access full facility in an emergency. Residents with Special Health Needs: The facility does accept dementia residents in care. The facility currently has residents receiving Home Health services. Refer to LIC 809-D Exit interview conducted and copy of report and appeal rights printed for Administrator.the state’s words, verbatim · CDSS document, Apr 22, 2024