Pre-licensing visit·June 24, 2021

Licensing Program Analyst (LPA) Ruth Martinez conducted an announced visit to the facility for the purpose of a pre-licensing evaluation. LPA arrived at the facility, was greeted by applicant and granted entry. An initial application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden resident was submitted to CCL on 09/08/2020. Structure: The facility is a white stucco structure with white trim one-story house with a garage with 6 bedrooms, 2 bathrooms/bedroom, 1 living room, and a restaurant style open kitchen. The client bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a large back yard with 1 exit ways on each side of the house with shaded seating area for residents. Signal system: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: Bedrooms are for 5 non-ambulatory and 1 bedridden. One bedroom will accommodate 2 residents being a shared room. Bedrooms Staff: 1 bedroom will be for live in staff. CONTINUED on LIC809-C Bathrooms: All bathrooms have a working toilet, wash basin, bath-tub/shower. Linens & Hygiene Supplies: Adequate supply of linen stored in hallway cabinet space. Emergency Phone Numbers, Exit Plan & Menu: Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food serve for one week. Food Service: Adequate supply of 7-day non-perishable and 2-day perishables are to be stored in the kitchen. There is an extra refrigerator in garage with food supply. Smoke Detectors: Smoke detectors and carbon monoxide alert systems are hardwired, were tested and found operational. Appliances: Gas four-burner stove, single oven, 2 refrigerator/freezer (kitchen and garage), dish washer, microwave, washer, and dryer are clean and noted to be operational. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients are stored and locked in a storage cabinet located garage. Water Temperature: Tested and recorded the water temperature measures 108.3 Fahrenheit degrees in all restrooms. CONTINUED ON LIC809-C Medications, First-Aid Kit & Book: Medication stored in storage cabinet with lock inaccessible to residents. Facility has 3 First aid kits is stored with medication and storage cabinet. Clients & Staff Files : Records will be kept locked with medication cabinet. Pool/Jacuzzi & Pets: No bodies of water in facility. Fire Extinguisher: Mounted in wall dated October 07, 2020. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the residents use, commensurate with the plan of operation. Fire clearance: Was approved on 11/23/2020. Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance. All items reviewed during the visit are in compliance. Facility appears to be ready for licensure. Accordingly, LPA will submit file for approval to CCL Supervisor. Exit interview was conducted and a copy of this report was left with the applicant.