Pre-licensing visit·August 21, 2025

On this day, August 21, 2025, at 11:00 am, Licensing Program Analyst (LPA) Delmundo conducted an announced pre-licensing inspection. License application is for four (4) total capacity, all non-ambulatory. Fire clearance was granted on June 2, 2025. LPA met with Haidar Hadi, applicant. Application is an initial/new application for license for this location. LPA toured the facility inside out. There is no body of water. LPA inspected the living room, dining area, kitchen, bedrooms, bathrooms, front, side and backyard. Central storage for medications was observed in the garage. Fire extinguisher was observed fully charge and when verified, applicant stated it was purchased this year. LPA discussed for it to be serviced every year. Carbon monoxide and smoke detectors were tested and observed in operating condition. First aid kit was checked and observed complete with manual LPA observed the following: -the home has renter. LPA verified, and according to applicant all the furniture, kitchen utensils, cook ware, plates and microwave are owned by the renter. -at 11:10 am, cracked kitchen counter, rusted sink. -at 11:16 am, bed in the living room. -at 11:20 am, mildew in the shower of the common bathroom, no grab bar in the shower, dirty toilet/shower, rusted towel paper holder, trash can without lid. ....continued on 809C -at 11:30 am, ensuite bathroom dirty and with mildew, no grabs and non-slid mat, trash can without lid. -at 11:32 am, rake, pieces of wood and metal, pieces of car doors, pails of paint, paint brush and pan, block of cement, tiles, weed killer, old chair and table in the side yard. -at 11:36 am, uneven cemented area and with crack, broken mirror, pieces of wood and glass, bricks, pile of decorative cement blocks, worn out mattress and chair and headboard in the backyard. -Complaint and Ombudsman posters, Residents Personal Rights, Rights to Resident Council, Rights to Family Council, Theft and Loss Policy not posted. -facility sketch not consistent with the sketch submitted to Centralized Applications Bureau - orientation not correct, doors of the 2 bedrooms and closets in these bedrooms incorrectly labeled/indicated in the sketch. -no call buttons for residents' use. -fire extinguisher still in the box. -no linens, paper towels and toilet paper, towel, wash cloths, hygiene supplies and non-perishable food supplies available. -scratched, dusty flooring. -no flashlights available; no telephone and internet service; no patio furniture in the yard. Applicant stated he'll submit the proof of corrections (POCs) by October 21, 2025 for the following: 1. Have the renter move out. 2. Replace the kitchen counter and sink. 3. Install grab bars in the toiler and shower; clean the bathrooms; purchase trash cans with foot operated pedal lids. 4. Have the cement in the backyard leveled and repair the crack. 5. Clean the yard. 6. Replaced the flooring with industrial grade vinyl tiles. 7. Purchase the following: living room furniture; bedroom furniture including beds, bed frames, night stands and drawers; washer; microwave; kitchen utensils; silver wares; pots and pans; plates; flashlights; call buttons for residents' use; patio furniture 8. Mount the fire extinguisher. 9. Install lock in the closet by the dining area to be use as central storage for medications. ....continued on 809C 10. Post the following in the prominent place in the facility: Complaint and Ombudsman posters, Residents Personal Rights, Rights to Resident Council, Rights to Family Council, Theft and Loss Policy. 11. Call the telephone and internet service provider(s) for job order. Applicant stated he wants to convert the staff bedroom to residents' room and increase the capacity from 4 to 5. The following to be submitted by October 21, 2025: 1. LIC200 for 5 total capacity. 3. Corrected/updated sketches showing the following: -Exit doors and windows -Dimensions and use of each room -Number of resident(s) in each bedroom -Utility shut off locations -correct locations of closets and doors - Outside sketch showing the building, perimeter fence, driveway and utility shut off locations. Upon receipt of LIC200 and updated sketches, LPA to submit to Centralized Applications Bureau analyst who in turn will submit a new request for fire safety inspection. LPA to do re-inspection once the new fire clearance is granted and corrections to the deficiencies are completed. LPA discussed obtaining $3M liability insurance upon admission of first resident and to submit copy of the insurance certificate to LPA. Exit interview conducted and copy of this report provided to applicant.