Pre-licensing visit·September 10, 2021

Licensing Program Analysts (LPAs) Kruz Long conducted an announced visit to the facility for the purpose of a pre-licensing evaluation. An application was received for Initial License #198603495 Residential Care Facility for the Elderly age range 60 and over. The requested capacity is for 6 only. The facility is a single story house which consist of a living room, kitchen, dining area, 4 Resident bedrooms, 2 bathrooms and a laundry room. The resident bedrooms are spacious and will easily accommodate the resident's furnishings. The front yard contains a cover patio area. Passageways, walkways, driveway, and patios are free of obstructions. Front, back and side areas are free of hazards. All resident bedrooms contain beds, chairs, night stand, lamps in addition to overhead lighting. Bathrooms have a working toilet, wash basin, bathtub/stand up shower equipped with non-skid matts and grab bars. Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Emergency Phone Numbers, Exit Plan & Menu are posted & readily available for review. Fire Extinguisher located in the kitchen mounted to the wall. Telephone system is a land line located in the living room. Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked drawer in the kitchen. Smoke Detectors and Carbon monoxide detector are operational. Stove burners, oven, microwave, washer, and dryer working. There are two refrigerator in the kitchen. Toxins are stored and locked under the kitchen sink. Water Temperature measured within Title 22 guidelines in the kitchen. A first aid kit has been inspected and consist the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in the kitchen available for staff use but inaccessible to residents. Medications and records will be stored in a locked cabinet in the dining area. The facility has board games, books, and other recreational materials for the resident's use in the living room. There are no Pool/Jacuzzi & Pets on the premises. Fire Clearance was approved on 06/15/2021. All exit doors is equipped with an alert devise. Continue to LIC809C......... Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance. During the pre-licensing inspection, LPA did not observe items which do not comply with applicable laws and regulations. An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.