Pre-licensing visit·March 17, 2022

Licensing Program Analysts (LPAs) Alicia Delmundo and Liridon Ficci conducted an announced pre-licensing inspection. License application is for six (6) total capacity, all non-ambulatory of which one maybe bedridden. Fire clearance was granted on January 25, 2022. LPAs met with Sharon Astera, applicant-administrator. LPAs toured the facility inside out. There is no body of water. Facility is equipped with fire sprinkler. LPAs inspected the living and family rooms, dining area, kitchen, bedrooms, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed sufficient good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet to store knives and centrally store medications was observed with lock. A central screening table for staff and visitors was observed set-up close to the entrance door. Bathrooms/showers were observed equipped with grab bars and non-skid mats. Complaint poster, Ombudsman poster personal rights, Theft and Loss Policy, Rights to Resident Council and Right to Family Council were observed posted in the prominent place. Fire extinguisher was observed fully charge and serviced March 15, 2021. Carbon monoxide and smoke detectors operational. First aid kit inspected. Facility has flash lights for emergency lighting. Hot water temperature in one of the bathrooms were tested and measured at 112 degrees Fahrenheit. .....continued on 809C (page 2) Page 2 LPAs observed the following: 1. Physical plant is not consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. Ensuite bathroom in the front bedroom not indicated in the sketch. 2. Fireplace with no screen cover. 3. Common areas (dining, living room and family room) do not have COVID-19 signages. 4. No trash bins in all 3 bathrooms. 5. No grab bars on 3 toilets. 6. No paper towel dispenser in two bathrooms.. 7. Storage in the side yard no lock. 8. Pieces of wood and collapsed boxes in the side yard. Pieces of wood and bags of cement in the backyard 9. No auditory signals on entrance and exit doors. 10. No call button for residents' use. 11. Stove knobs no cover. 12. PPEs missing disposable gowns 13. First aid kit has no scissors. 14. No facility phone. Applicant stated that she wants to increase the bedridden from 1 to 2. Applicant to submit the following proof of corrections (POCs) by March 31, 2022: Picture showing cover installed on fireplace and COVID-19 signages posted. Proof of purchase for trash bins with foot pedal operated cover. Proof of purchase and picture of paper towel dispenser. Picture showing grab bars, auditory signals installed and locked storage in the side yard. Proof of purchase for call buttons, disposable gowns, stove knob covers and scissors. Pictures showing side and back yard cleaned. .....continued next page (page 3) Page 3 Updated sketches showing the following: -Dimensions and use of each room (e.g. staff bedroom, residents bedroom) -Number of resident in each bedroom -Utility shut off locations -Exit doors and windows - Outside sketch showing the building, driveway, perimeter fence and storage in the side yard LIC200 Application for 6 total capacity (4 non-ambulatory & 2 bedridden) Proof of activated phone service and provide telephone number. Upon receipt of LIC200 and updated sketches, LPA to submit to Central Application Bureau (CAB) analyst who in turn will submit a new request for fire safety inspection. LPA will inform CAB analyst when POCS for the other deficiencies are received. LPAs reminded applicant to obtain $3M liability insurance upon admission of first resident and submit copy to LPA. Final review of application and license to be granted by CAB analyst. Exit interview conducted and copy of this report provided to Sharon Aranha.