Pre-licensing visit·March 13, 2025

Licensing Program Analyst (LPA) Delmundo conducted an announced pre-licensing inspection. License application is for six (6) total capacity, all non-ambulatory. Fire clearance was granted on January 22, 2025. LPA met with Thinn Aye, applicant-administrator, and Jovany Sarabia, future staff. LPA toured the facility inside out. There is no body of water and fire place. LPA inspected the living rooms, dining area, kitchen, bedrooms. 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. Bathrooms with showers were observed with grab bars and non-skid mats. 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 centrally store medications was observed with lock. Facility has call buttons for residents use. Fire extinguisher was checked. Smoke detectors were tested and observed in operating condition. First aid kit inspected and observed complete with manual. Facility has flash light for emergency lighting. Hot water temperature in one of the bathrooms was tested and measured at 109.6 degrees Fahrenheit. Complaint and Long-Term Care Ombudsman posters and Theft and Loss policy were observed posted in the prominent place in the facility. .....continued on 809C (page 2) Page 2 LPA observed the following: -cabinet under the kitchen sink and common bathroom where cleaning supplies are to be kept do no have locks. -range/stove knobs without covers -camera in the common area with feature that capture audio. Corrected on this same day - staff removed the camera. -no carbon monoxide detector. - no auditory signals on 3 other exit doors including the sliding door in one of the residents' rooms leading to the side yard. -strong smell of urine in the ensuite bathroom in the resident's room. -ladder, pieces of wood, rolls of chicken and barb wires, pails of paint, used paint pan, pieces of metal, piece of granite slab, 2 pieces of backer boards, collapsed box, wet pet beds, bag of cement, empty coffee canister in the side yards. -no Right to Resident Council and Right to Family Council posters. Corrected - staff posted the posters. -facility sketch received by Central Application Bureau (CAB) and approved by the fire department not consistent with the physical plant - 2 staff rooms added to the garage. There were cleaning and laundry supplies but the garage does not have lock. Applicant to do and submit the following proof of corrections (POCs) by March 27, 2025: -install locks in the cabinets. -purchase range/stove covers. -purchase and install carbon monoxide detector. -install auditory signals on the exit doors. -have the bathroom cleaned and submit self-certification. -have the yard cleaned. -install lock in the garage. ......continued on 809C (page 3) Page 3 -have the fire extinguisher serviced. - submit updated facility sketch showing the following: -Exit doors and windows -Dimensions and use of each room -Number of resident in each bedroom -Utility shut off locations -Driveway - Garage showing the 2 staff rooms On this same day, LPA received a signed letter from applicant requesting for update of facility telephone number. Upon receipt of updated sketch, LPA to submit to Central Application Bureau (CAB) analyst who in turn will submit a new request for fire safety inspection (STD850). LPA will also inform the CAB analyst when POCs for the other deficiencies are received. License to be granted by CAB analyst upon receipt of approved STD850 from the fire department and final review of application. Exit interview conducted and copy of this report provided to the applicant.