Pre-licensing visit·August 30, 2021

An unannounced Pre-Licensing inspection visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. When arriving to the property LPA contacted administrator to complete the pre-inspection COVID 19 questions. Upon entrance to the facility LPA met with staff Edgar Prepuse and Marissa Agngarayngay. Temperature check and screening for LPA was completed by staff. BEDROOMS: The physical plant was toured inside and out. A fire clearance was approved on 7/26/2021 for the following. Room # 2 is cleared for 2 ambulatory, Room # 3 is cleared for 1 non-ambulatory, Room # 4 is cleared for 1 non-ambulatory and Room # 5 is cleared for 2 non-ambulatory one of which may be bedridden. This facility has four resident bedrooms. One out of four rooms (Room #5) has a direct exit to the exterior. Rooms were set up with beds, night stands, lamps, chests of drawers, chairs and closet space. Lighting in the rooms was adequate. Room # 1 is the designated staff room. BATHROOMS: There are 2 full bathrooms. One out of four rooms (Room #5) has an en-suite bathroom. Bathrooms are clean and sanitary and in operating condition with appropriately stalled grab bars and non-skid mats in the showers. KITCHEN: Kitchen knives and sharp objects will be kept locked and inaccessible in locked drawers, Kitchen appliances were in operable condition. The facility had a sufficient supply of non-perishable food. The supply of dishes was adequate. The fire extinguisher is in the kitchen and was inspected in 5/2021. There is adequate seating for dining in the dinning are. Medications will be stored in a locked cabinet in the kitchen. There was a washer and dryer area in the kitchen near the staff room. COMMON AREAS: The common areas were appropriately furnished, and lighting was adequate. The LPA observed a fireplace in the living room which was screened and inaccessible. The smoke alarm system is hard wired. Smoke and carbon monoxide detectors were tested and were operational at the time of the visit. The facility had a complete first aid kit. Required postings were not observed throughout the facility. A discussion was held with the applicant who stated she will ensure to post all information as required upon licensure. OUTSIDE AREAS: The exterior passageways were clean and clear of any obstructions. The backyard has a covered outdoor area equipped with furniture for resident use. There are no bodies of water noted at this time. Component III was conducted with applicant in conjunction with this visit. While conducting review of the residents records it was observed that resident 1 R1 is who is non-ambulatory and utilizes a wheelchair is residing in room #2 which is currently fire cleared for 2 ambulatory. Administrator will speak with the residents and/or their responsible parties to determine what room changes will be made. Once completed Administrator will notify the LPA In writing. Administrator will also submit an updated facility sketch which complies with the fire clearance that was granted in July. The administrator was informed that she will need complete all corrections identified in this report and discussed during the visit in order to complete the change of ownership process. Once the corrections are made LPA will notify the Centralized Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. Exit interview conducted with applicant, and copy of report emailed to the applicant.