Pre-licensing visit·January 10, 2025

Licensing Program Analyst (LPA) Trevor Byrne conducted a pre-licensing visit to the above noted facility. The LPA met with applicant, Varduhi Sirunyan This is a new facility application. A dementia program was included in the plan of operation. A Hospice Waiver has been requested. The facility is one story. At 09:19 AM, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for five (5) non-ambulatory residents; and, one (1) bedridden resident. The facility has two (2) private resident bedrooms, Rooms # 2 and 4 and two (2) shared rooms, Rooms # 1 and 3. Room number four (4) is the approved bedridden room and has a direct exit to the outside. Rooms # 1, 2, and 3 are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket and a bedspread. Lighting in the rooms appeared adequate. Bedroom # 4 was observed to be missing all required furniture. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. There are no staff rooms, awake night staff is required. All rooms were free of odors. Ripped window screens were observed in the living room, bedroom #1, staff bathroom, the private bathroom attached to bedroom # 4. There is one (1) bathroom in the hallway and one private bathroom attached to bedroom #4. Bathroom number three (3) is designated as a staff bathroom. The resident bathrooms have a shower with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105*F and 120*F. Continued on LIC 809C. Resident and staff records are stored in a locked cabinet which is currently located in the kitchen. Medications are centrally stored in a locked cabinet in the kitchen. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were stored in the infection control station at the entrance to the facility. Kitchen knives are stored in a locked drawer in the kitchen. Stove burners are rendered inaccessible to the residents by removing them when not in use. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable food is adequate. There are no pesticides, poisons, or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in locked cabinets located in the kitchen and the laundry room. No flies or other vermin were observed. The common areas were appropriately furnished, and the lighting was adequate. There are entertainment equipment, games and activity supplies in the living room and dining area. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to nonprivate bathrooms. All ramps observed were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. The front pedestrian entrance and the sliding door in the living room were observed to be missing ramps. There is a fireplace in the living room. It is screened and there are no tools. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit. The facility smoke alarm system is hard wired. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There is one (1) fire extinguisher throughout the house. It is fully charged and does not exceed the expiration date. Continued on LIC 809C. Hot water was tested in each bathroom, which included the resident bathrooms and any common bathrooms, in addition to the kitchen; and, the hot water ranged from 108 to 118.9 degrees Fahrenheit. The laundry area is located in a room adjacent to the kitchen. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in a locked hallway closet. Extra incontinence supplies are stored in a hallway closet. There are two (2) functioning telephone on the premises. The emergency exiting plans/sketch are posted throughout the facility and in each resident room. The emergency telephone numbers along with other required postings are posted on the wall in the living room of the facility. The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the back of the house with tables and chairs where residents can sit. The entire property is fenced. The back and sides of the house are separated from the front yard by a gate on the side of the facility. The gate to the driveway is moved automatically. There is a door w/gate with a self-latching mechanism for persons to enter the front yard. There is a separate address attached to the facility that is not associated with the facility. There is a pool located in the backyard of the facility. It is appropriately fenced and made inaccessible to residents when not in use. COMP III orientation was completed with the applicant during this pre-licensing inspection. The following items must be corrected prior to licensure. Submit proof of corrections, along with a copy of this report, to LPA Trevor Byrne so that your application may be completed. 87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building Continued on LIC 809C. 87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (A) A bed for each resident, except that married couples may be provided with one appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. Fillings and covers for mattresses and pillows shall be flame retardant. Rubber sheeting shall be provided when necessary. 87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. 87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. 87303 Maintenance and Operation (c) All window screens shall be clean and maintained in good repair. Continued on LIC 809C. This report will be sent to the Centralized Application Bureau (CAB) once all corrections are received. You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.