Aaa Kindness Care Ii.

Licensing Program Analyst (LPA) Melisa Rankin arrived at 8:55 a.m. to conduct a 1-year required annual visit. LPA met with Shayna Pettiford, Administrator. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: The facility has one large, assisted living building with 3 wings and 24 rooms. LPA toured the dining room, kitchen, sunshine room, sunroom, laundry room, and 5 resident rooms. Physical Plant & Environment Safety: LPA was authorized to enter and inspect facility. LPA toured resident rooms and observed that rooms were tidy. The lighting and lamps are sufficient for the use of the facility and for resident comfort and safety. Toilet, hand washing and bathing facilities are operational and secure grab bars are present. Most rooms have their own private restroom, and 4 rooms share a restroom. All residents and public bathrooms observed were sufficiently stocked with soap and paper towels. The showers have slip-resistant mats, and the newer build has slip resistant flooring. The pathways are clear of any obstructions. Disinfectant and cleaning solutions are inaccessible to residents in care and are stored in the locked laundry room and a locked hall closet. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced yard for client use with plenty of shade. The facility has telephone and internet service for residents’ use. The fire extinguisher was last charged and inspected on 9/9/25. The facility has a fire sprinkler system that was last inspected in August of 2025. Each resident room located in the North and South wings of the facility have a carbon monoxide detector which is tested quarterly, LPA tested 3 carbon monoxide alarms. Continued on 909-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Operational Requirements: The facility has a current plan of operation on file with the department. The facility has current liability insurance. The facility is approved for a capacity of 32. The fire clearance is granted 20 non-ambulatory residents, of which 7 may be bedridden and 5 ambulatory residents. A hospice waiver is approved for 10 residents. The facility currently has 25 residents. There are 4 residents on hospice care. Staffing, Personnel Records & Training: The facility currently employs 24 staff and 1 administrator. LPA reviewed five (5) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid/CPR. All files were complete. Administrator’s Certificate expires on 7/19/27. The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours 2025. 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 five (5) resident files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and current plan of care. All files were complete. Food Service: The facility has 2-day perishables and 7-day non-perishables to meet the food service requirements. Knives are stored in a locked drawer in the kitchen. Kitchen appliances were in operable condition. The freezer is kept at 0 degrees, and the refrigeration is kept at 40 degrees or lower. Cleaning solutions and equipment are stored separately from food supplies. Incidental Medical Services: Facility provides transportation or assists in providing transportation to medical and dental appointments when needed. The facility uses the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed a sampling of 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 are located in a binder at med tech desk. The facility conducts quarterly disaster drill/training. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Residents with Special Health Needs: The facility accepts dementia residents in care. The facility does not have delayed egress, and does not lock residents into facility grounds. Exit interview conducted and copy of report printed for Administrator.

Licensing Program Analyst (LPA) Erika Miller arrived at 8:30 a.m. to conduct a 1-year required annual visit. LPA met with Sheryll Ann Saniatan, Back-Up Administrator. 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 facility has at least a 30-day supply of PPE. 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). Physical Plant & Environment Safety: LPA was authorized to enter and inspect facility. LPA toured 10 resident rooms and observed that rooms were tidy . 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 slip-resistant mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant and cleaning solutions are inaccessible to residents in care and locked in laundry room. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use with plenty of shade. The facility has telephone and internet service for resident use. The fire extinguisher was last charged and inspected on September 16, 2024. The facility has smoke and carbon monoxide detectors that were tested and/or inspected. Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance. The facility is approved for a capacity of 32. The fire clearance is granted 20 non-ambulatory residents, of which 7 may be bedridden and 5 ambulatory residents. A hospice waiver is approved for 6 residents. The facility currently has 18 non-ambulatory residents and 3 ambulatory residents. There are currently 4 residents on hospice care. Continued on 909-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Staffing: The facility currently employs 20 staff and 1 administrator. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. Administrator Certificate expires on 7/20/25. Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours 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, Personal Rights, Safeguard for property and valuables, Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms. All forms were legible. Food Service: . The facility has 2-day perishables and 7-day non-perishables 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. Incidental Medical Services: Facility provides transportation or assists in providing transportation to medical and dental appointments when needed. The facility uses 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 last conducted a quarterly disaster drill/training on December 16, 2024. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Residents with Special Health Needs: The facility accepts dementia residents in care. The facility does not have delayed egress, locked doors or gates. Exit door alarms are working. Exit interview conducted and copy of report printed for Administrator.

Licensing Program Analyst (LPA) Jenny Olson arrived at the facility unannounced to conduct a required annual visit at 11:11 a.m. When LPA arrived, there were seven staff plus Administrator and 22 residents present. LPA was greeted by staff and Administrator shortly after and LPA informed them of the reason for the visit. LPA 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 facility has one large assisted living building with 3 wings and 24 rooms. LPA toured the dining room, kitchen, sunshine room, sun room, and 10 resident rooms. Common areas: All furniture was observed to be in good condition. Carbon monoxide detectors were tested and operational at the time of the visit. There is a fireplace in the living room, which is screened and inaccessible. LPA observed required postings throughout the common spaces. The fire extinguishers were charged and serviced on 9/12/2023. Outdoor area had a gazebo which is equipped with furniture for resident use. No bodies of water noted. Washer and dryers were functioning and in operable condition. Restrooms: 23 restrooms were clean and sanitary and in operating condition with non-skid mats. Most rooms have their own private restroom and 4 rooms share a restroom. All resident and public bathrooms were sufficiently stocked with soap and paper towels. KITCHEN: Knives are stored in a locked drawer in the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Continued on 809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Records: LPA reviewed resident and staff records around 3:00 p.m. LPA reviewed five (5) resident files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and current needs and services plan. All files were complete. LPA reviewed five (5) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid certification. All files were complete. MEDICATIONS: Medications review began at 2:00 p.m. The medications are centrally stored and locked in a med cart in the foyer. Medications are labeled and checked for expiration dates. All the necessary information is properly documented on the CSMDR! INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. The facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate. LPA interviewed three (3) staff members and three (3) residents. During today’s visit, the LPA obtained copies of the following: staff roster and current liability insurance. Exit interview conducted a copy of this report was issued.