Tc Cares III

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Annual Required 1 Year Visit with the primary focus on infection control measures and the use of the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the evaluation, the facility is clear of COVID-19 infection. LPA Bunker met with Licensee/Administrator Henry Wallace and explained the purpose of today's annual inspection. LPA verified that the facility has an approved Mitigation Plan Report and Infection Control Report. There are currently no residents in placement, and the facility’s annual fees are up to date. The following 12 Domains will be observed and reviewed: Infection Control, Operational Requirements, Physical Plant & Environmental Safety, Staffing, Personnel Records-Training/Staff Training, Resident Rights-Information, Planned Activities, Food Service, Incidental Medical and Dental, Resident Records/Incident Reports, Disaster Preparedness, and Resident with Special Health Needs. "LPA Bunker will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections." LPA Bunker and Licensee/Administrator conducted a tour of the facility, which is a single-story family home located in a residential neighborhood. The home includes a living room, dining room, kitchen, three bedrooms, one bathroom, a laundry room, a detached garage, and an indoor/outdoor activity area. Bedrooms #1-3 are designated as the resident's bedrooms. There is a shaded outdoor space furnished with patio furniture, including tables and chairs. See continued LIC809-C page 2 Continued LIC802-C page 2 LPA Bunker observed the facility’s infection control practices, which included screening protocols for residents and visitors, the availability of hand sanitizer, a visitor log, and the use of thermometers in the facility's living room. Logs documenting daily COVID-19 screenings and temperature checks for both residents and staff were available and up to date. Personal Protective Equipment (PPE) supplies were readily accessible to staff, and an additional supply of PPE was also observed. Additionally, sufficient liquid soap, paper products, cleaning supplies, and disinfectants were available. Required documents are posted on the bulletin board located on the kitchen wall. The following Title 22-regulated areas were audited and found to be in compliance: • Telephones: Facility telephones are operational. • Bedrooms: All bedrooms meet the required standards for furniture, safety, privacy, and comfort. An adequate supply of linens is available. • Bathroom: The bathroom is clean, fully operational, and equipped with non-skid surface mats to ensure safety and privacy. • Kitchen and Food Service: Kitchen and Food Service: The kitchen is adequately equipped for food preparation and service. A review of food supplies confirmed an ample stock of both perishable and non-perishable items, stored in an appropriate manner. • Medication Storage and Management: All medications will be securely stored in a locked cabinet located in the entryway closet. Documentation will remain current to ensure accurate records and full compliance with storage requirements. • Common Areas: The living room, dining room, and other shared spaces are well-maintained, free of hazards, and meet cleanliness standards essential for resident safety and well-being. See continued LIC812-C page 3. Continued LIC812-C page 3. • Safety Equipment and Measures: The facility is equipped with a fully stocked first aid kit and manual, functional smoke and carbon monoxide detectors, and properly charged fire extinguishers. Hot water temperature was measured at 120°F, within the acceptable range of 105–120°F. • Emergency Preparedness: All exit doors are in compliance. Bedroom windows are fitted with sliding locks that do not use thumbscrews. • Environmental Safety: The yard is free of debris and hazards. Trash cans are covered, and there are no firearms or bodies of water on the premises. Hazardous items are stored securely and remain inaccessible to clients. • Staff Training: Staff have received training on dependent adult and elder abuse reporting. • Administrative Compliance: The Administrator’s Certificate is current. HIV/TB compliance requirements have been verified. LPA Bunker provided Licensee/Administrator Henry Wallace with a copy of the facility evaluation report, LIC809, and LIC809-C. No deficiencies were cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, Feb 19, 2026

Type of visit: Prelicensing

On 01/22/2025, Licensing Program Analyst’s (LPA’s) Yolanda Rosser conducted an Announced Pre-Licensing visit. LPA Rosser met with and toured the facility with Licensee Henry Wallace. The facility plans to support individuals who are 60 years of age and above. The facility has a fire clearance for (6) ambulatory residents. The facility is a single-story residence to include three bedrooms and one restroom. LPA Rosser observed the following during a tour of the facility Fire Extinguisher was purchased 07/03/2024, living room with new couch and love seat, with space for activities (games and activities were located in a storage area underneath the television, dining room area with space to accommodate four (4) people, kitchen with table and chairs to accommodate three (3) people. The areas inspected have the required furnishings, lighting, and storage. LPA, observed 3 days of non- perishables and 7 days of perishables. LPA Rosser toured the detached garage used strictly for storage and is non-accessible to residents. The backyard has a block brick wall surrounding it. The backyard has a seating area with chairs and a tent for shade. The front yard landscape is neat and clean. The walkways around the facility are free of obstructions and no debris. The entrance is equipped with a ramp. LPA Rosser conducted a test of the smoke and carbon monoxide detectors and found them to be functioning properly. continued on LIC 809 C The residence has a washer and dryer unit. There is extra lighting and batteries. The cutlery's were stored and locked. Entrance closet will maintain medication and employee records which has a lock on the door. The residence has extra linen, blankets, pillows and towels. Extra hygiene items were stored in hallway closet. The bedrooms met Title 22 requirements. The residence is very neat and clean. All poster and signage were posted. An exit interview was conducted, and a Facility Evaluation Report and Appeal Rights were provided to Henry Wallace, Administrator..the state’s words, verbatim · CDSS document, Jan 22, 2025

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Method: Telephone call with CAB COMP II Participants: Wallace, Henry On 11/12/24, the applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming driver’s license number. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Nov 12, 2024