Pre-licensing visit·March 29, 2024

Licensing Program Analyst (LPA) Mora conducted an announced Pre-Licensing visit using the CARE Tool. LPA met with Hiransha S Keerthisinghe (Licensee) and explained the reason for the visit. A change of ownership application was submitted to Community Care Licensing Department (CCLD) for a Residential Care For Elderly facility to serve six (6) non-ambulatory residents, of which two (2) may be bedridden in the age range of 60 and over. Facility is approved for 6 hospice waivers. A tour of the single-story facility included: 4 resident bedrooms, 1 staff bedroom, 3 resident bathrooms, living room, kitchen, dining area, office area, front yard, backyard, and de-attached garage. LPA and Hiransha Keerthisinghe toured the facility and the following was observed: sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Auditory devices were seen on all exit doors which are required for dementia residents and were operating at the time of the visit. The water temperature was tested and measured at 110.2 degrees F which is within the required 105 - 120 degrees F. The bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. The shower has non-skid material. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have enough closet space. Resident beds have the required linen and the linen is in good condition. There is extra clean linen and towels in each bedroom. Smoke detectors were observed in each room and throughout the facility and are properly operating. A carbon monoxide was observed in the kitchen and it is properly operating. A fire extinguisher was observed in the hallway which is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are kept locked in a kitchen cabinet. Chemicals and cleaning supplies are kept locked under the kitchen sink. First Aid kit was fully stocked with current manual and it is kept locked in the medication cabinet. The front and backyard are well maintained. There is a shaded seating area for the residents located in the backyard. There are no bodies of water at the facility. Passageways and exits are free of obstruction. Residents medication are centrally stored in a locked living room cabinet. Residents and staff files are centrally stored in a office area cabinet. LPA reviewed medication for 6 of the residents and observed that medications are documented properly and given as prescribed. LPA reviewed files for all 6 residents and 5 staff. No deficiencies were found with the files. LPA observed administrator certificate for Hiransha Keerthisinghe with an expiration date of 05/12/2024. (Continued to LIC 809-C) No outstanding or pending items were observed by the LPA requiring additional pre-licensing visits. LPA will notify the assigned Centralized Applications Bureau (CAB) Analyst of the completed pre-licensing facility evaluation visit conducted, which included the Component III Orientation. Exit interview conducted and a copy of this report was provided to the licensee.