Pre-licensing visit·April 25, 2022

Licensing Program Analysts (LPA) Jill Clancy-Czuleger conducted an announced pre-licensing inspection. License application is for six (6) total capacity, of which 5 maybe non-ambulatory and 1 maybe bedridden. Fire clearance was granted on March 28, 2022. LPA met with Margaret Hsu (applicant administrator). LPA inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, 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 good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Activity supplies were available. Fire extinguishers were observed fully charge. There is a carbon monoxide detector in every room. Both the carbon monoxide and smoke detector tested and observed functional. First aid kit checked and observed complete with manual. Hot water temperature in one of the bathrooms tested and measured at 116.2 degrees Fahrenheit. ....continued on 809-C LPA observed the following: 1. latch on exit gates 2. lack of signage for facility LPA discussed the following: 1. Posting signs throughout the facility 2. Moving latch on exit gate to the inside for emergency’s Upon receipt of the proof of corrections for the 2 items above, and proof of N95 fit testing by May 16, 2022, LPA Clancy-Czuleger will inform CAB. Issuance of license is pending upon final review by CAB analyst. Exit interview conducted and copy of this report provided.