Pre-licensing visit·March 16, 2022

On 03/16/2022, Licensing Program Analyst (LPA) A. Walton conducted an announced Pre-Licensing / Component III inspection. LPA Walton introduced self, stated purpose of visit, and was allowed entry into the facility. LPA met with: Licensee: Jessica Johnson Administrator: Denise Ordoniez The facility is a 3 Bedroom and 3 Bathroom home and fire clearance was granted for 2 Ambulatory and 2 Non-Ambulatory for a total of 4 Capacity. LPA toured the facility with Licensee. Common areas were furnished and had adequate seating and lighting available. Bedrooms had required furnishings and are ready for occupancy. LPA observed the smoke detector in bedroom 3 to be detached from the ceiling. The carpet in bedroom 3 was observed to be lifted from the floor and not fully installed. Hot water measured at 129.3 degrees F in the bathroom in bedroom 3, 124.2 degrees F. in the hallway bathroom and 111.3 degrees F. in the Activity bathroom. Grab bars observed to be in the shower area, no grab bars observed by the toilet. LPA observed a short supply of bed linens and an adequate personal hygiene products. Kitchen was toured and observed to have dishes, plates, and utensils. Cleaning supplies and chemicals were observed to be locked in the laundry room. Medications will be locked in a cabinet in the kitchen. First aid kit was observed and contained all required items. A fire extinguisher was observed and did not have a service date. Smoke detectors and carbon monoxide were observed to be operational during this inspection. Outside of facility toured. Exits were open and free of obstructions. LPA observed side gate to be self-latching. CONTINUED TO LIC809C LPA requested Licensee to correct the following items: Reattach smoke detector to the ceiling in bedroom 3 Secure the carpet to the floor in bedroom 3 Adjust water heater to allow facility water temperature to be within range Have fire extinguisher serviced Obtain additional bed linens to permit changing for once per week that includes blankets and bedspreads. Install grab bars near the toilets Component III was conducted during today’s pre-licensing visit. Exit interview conducted. A copy of this report will be provided to Licensee via email due to COVID-19 precautionary measures. Report signed on-site by facility representative. LPA will notify CAB that facility is ready to be licensed once the above information has been received.