Pre-licensing visit·October 16, 2023

On 10/16/23, Licensing Program Analyst (LPA) M. Yang conducted an announced Pre-licensing and Component III inspection. LPA introduced self, stated the purpose of the visit, and was granted entry into the facility. LPA met with Licensee Leticia Jackson. LPA toured facility with Licensee. The facility is 4 bedroom and 2-bathroom home. Fire clearance was granted for 6 non-Ambulatory for total of 6 capacity. LPA toured the facility with Licensee. All four residents were present during this inspection. LPA observed 2 bedridden residents in bedroom 1 and bedroom 3. The facility was observed to be at a comfortable temperature of 76 degrees F, furnished with adequate seating. A fire extinguisher was observed and has a service date of 01/11/2023. Medications were kept locked in kitchen shelf. Kitchen was toured and observed to have dishes, plate, and utensils. An adequate supply of perishable and non-perishable food was observed. Freezer temperature was maintained at -4 degrees F and refrigerator temperature was maintained at 40 degrees F. Knives were observed to be locked and secured in kitchen shelf. Cleaning chemicals was observed stored and locked in under kitchen counter. LPA observed an extra supply of bed linens and personal hygiene products. Bedrooms were observed to have required furnishings. All bathrooms toured and operational during inspection. LPA observed bathroom with securely fastened grab bars and non-skid mat. Hot water measured at 111.8 degrees F in bathroom 1 and 105.9 degrees F in the master bathroom. Washer and dryer observed operational during inspection. Outside of facility toured. LPA observed side gate to be self-closing. Carbon monoxide and smoke detectors were tested and observed to be operational. First aid kit observed to have all required items. All resident records were reviewed. LPA observed resident Admission Agreements, Physician Reports, and Pre-Appraisal. Staff records were reviewed. Personnel records observed to have a criminal record clearance. LPA have founded the facility have not met all the Pre-Licensing requirements. Component III was conducted during today's pre-licensing visit. An exit interview was conducted. A copy of this report was provided to Licensee, whose signature confirms receipt of this report.