Pre-licensing visit·April 17, 2024

Licensing Program Analyst (LPA) Abeye Duguma conducted an announced Pre-licensing visit at around 11:15 AM and met with the Licensee, Irena Raskopina . LPA conducted an entrance interview with the Licensee. LPA Duguma also observed that there were six (06) residents in the facility during the inspection. All residents appear to be clean and groomed. With the assistance of the Licensee, LPA conducted a facility tour of both the inside and outside. This is a single-story property. Fire Clearance is approved for six (06) non-ambulatory of which one (01) may be bedridden. Facility has five (05) bedrooms and three (03) full bathrooms for residents. One (01) out of five (05) bedrooms is semi-private and the remaining are all private single occupancy. All residents’ bedrooms were adequately furnished. The facility has a designated staff room/office with its own bathroom. Facility also has a half bath for visitors near the front entrance. Resident bathrooms have properly installed grab bars and shower has non-skid mats. The average hot water temperature measured at 115.5ºF during the visit. The common areas were appropriately furnished. The LPA observed entertainment equipment and games for activities. The staff office has a designated storage cabinet for resident and staff records. The first-aid kit is complete. The facility has adequate linen, water, and emergency kits. The linens were stored in the storage space located in the hallway. The facility has working egress alarms on all exits. Smoke detectors and carbon monoxide detectors were checked and function properly. There is a fully charged fire extinguisher located between the kitchen and dining area. (CONT on LIC 9099-C) Receipt shows that fire extinguishers were purchased on 02/15/2024 and LPA advised the Licensee to retain the receipt of the fire extinguisher identifying the purchase date to ensure the time frame for annual inspection. LPA Duguma observed a washer and dryer in the laundry area. All chemicals, additional personal hygiene items were stored in the locked cabinets. The medications are stored in a locked cabinet in the office. LPA inspected the kitchen and observed stove and refrigerator to be clean and working. Knives and sharps are stored in a locked kitchen drawer. There is sufficient outdoor space with seating and a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises. At the time of this visit the physical plant is meeting Title 22 requirements. Component III was completed with the LPA. No health and safety hazard were noted during this visit. Exit interview was conducted and a copy of report was issued.