Pre-licensing visit·September 25, 2023

Licensing Program Analyst (LPA) Jenny Olson arrived at the facility announced at 12:30 p.m. to conduct a pre-licensing inspection. The LPA met with Joseph Jose, Executive Director. This is a change of ownership application from Clarendon Senior Living 2 197609026 to Clarendon Senior Living 2 195850244. The current capacity is for six (6) residents, the facility currently has four (4) residents. The fire clearance was granted on 02/27/2023; in which bedroom #1 was cleared for bedridden, and all other rooms, bedroom #2, #3, #4 #5 and #6 were cleared for non-ambulatory clients. There is one staff room. Applicant successfully completed Component II on 09/13/2023. Component III was waived as the applicant currently operates eleven (11) other Residential Care Facilities for the Elderly (RCFE)’s that are currently in good standing. Applicant has attended Component III in the past and is RCFE administrator certified. At 1:00 p.m., the LPA toured the physical plant areas inside and outside with applicant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN : Kitchen knives are stored locked and inaccessible in the drawer next to the kitchen sink. The supply of perishable and nonperishable food is adequate. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. Around 1:30 p.m. the hot water temperature in the kitchen measured around 115.6 degrees Fahrenheit. BEDROOMS : There are seven (7) bedrooms in the facility; the facility has six (6) bedrooms for resident use, and one (1) staff room. The staff room is kept locked. Lighting in the rooms appeared adequate. All resident rooms and one (1) staff room were set up with beds, nightstands, lamps, chests of drawers, chairs, and closet space. BATHROOMS : There are three (3) full bathrooms one in the main hallway and two Jack and Jill's (between room #4 and staff room, and room #5 and #6) designated for, residents, staff and guests. The showers are equipped with nonskid mats. Grab bars were observed in the bathrooms. Continued on LIC809-C COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment in the living room area. The facility smoke alarm system is hard wired; the smoke detectors and carbon monoxide were operable at the time of the visit. There is (1) fire extinguisher which was fully charged and last serviced on 09/20/2023. There is a functioning telephone on the premises. Emergency exiting plans/sketch, emergency telephone numbers, license, and personal rights are posted on the entry way wall. MEDICATIONS : Medications will be in a locked cabinet located in the facility dining room which is locked and inaccessible to residents in care. The first aid supplies were complete, including a first aid manual. FILES: Resident and staff records are stored in a book shelf located in the facility dining room. LAUNDRY : The laundry area is located in the attached garage which is locked and inaccessible to residents in care. EXTERIOR : The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the backyard with tables and chairs for resident use. There are no bodies of water noted on the premises. The facility has an attached garage used for laundry and storage. There are no other structures on the property. INFECTION CONTROL: The facility has an adequate supply of PPE and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. Facility is not compliance with Title 22 Regulations at this time. Applicant will be required to complete the following corrections and submit documentation to LPA Jenny Olson within 10 days: - Documentation of liability insurance. - Video of exterior gates able to self close and self latch. Continued on 9099-C Upon receipt of the above items, physical plant will be in compliance with Title 22 regulations. This report will be sent to the Centralized Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. The applicant is aware that they are unable to operate under the new license number until they have been notified that the license has been approved by the CAB Analyst. Failure to comply could affect approval of the license. Exit interview conducted, copy of report printed.