Pre-licensing visit·April 7, 2022

Licensing Program Analyst (LPA) Victoria Willis arrived announced to conduct a Pre-Licensing Inspection and was greeted by a caregiver. Applicant, Madonna Grace Martinez arrived later. Upon arrival, the on duty caregiver took LPA's temperature and LPA filled out a questionnaire with standard Covid-19 screening questions. Applicant has applied for a Change of Ownership at this location and there are already six residents in care. LPA initiated a tour of the facility at approximately 9:20am and made the following observations: Facility is a one story residence with four single resident bedrooms, one shared resident bedroom two bathrooms and common areas. All resident rooms are furnished with a bed, dresser, chair and bedside table, however, three of five resident bedrooms did not have a lamp. Bathroom showers have non-skid shower floors/mats and grab bars. Water temperature in tested bathroom read at 133 degrees F which is not within regulation of 105 & 120 degrees F. Facility has sufficient items used for cooking and eating. Perishable and non-perishable foods observed per regulation. Facility backyard has multiple areas for visiting and activities. Facility received an approved fire clearance dated December 3, 2021 that allows for six non-ambulatory residents. Fire Extinguisher was last serviced February 2022. Carbon Monoxide detectors were tested and operational. Facility has lighting in hallways. LPA confirmed that contents of the facility First Aid Kit were sufficient and that facility has emergency lighting in case of a power outage. Facility has a emergency supply of bottled water. LPA observed the CCL Complaint Poster in the main doorway. The Long Term Care Ombudsman Poster was in the kitchen but is blocked when the door is open. LPA requested that the Ombudsman Poster is moved to somewhere more conspicuous. Additionally, facility does not have Personal Rights or Rights to Resident Councils notifications posted. Continued on LIC809C Continued from LIC809 Medications and files are secured in the staff office and toxins/cleaning supplies are secured in a kitchen cabinet. LPA and Applicant discussed that all resident files would need to be updated upon Licensure. LPA confirmed that Applicant is signed up for the Guardian Provider Information Notices (PINs) that the department sends out. Component III was waived due to Applicant being a current Licensee. Applicant agrees to turn down water heater and send LPA a picture of water temperature reading within regulation, pictures showing that all residents have lamps for reading and all required postings on posted in a conspicuous place in order to move forward with Licensure. Once received, LPA will notify Application Unit so application process may proceed.