Pre-licensing visit·November 17, 2022

Licensing Program Analyst (LPA) Ruth Martinez conducted an announced visit to the facility for purpose of a pre-licensing evaluation. 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 09/06/22. Structure: The facility is a one story house with an attached garage with 5 resident bedrooms, 3 full bathrooms, 1 TV room, a kitchen. The resident’s bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a large back yard with 1 exit walkway on the side of the house with covered patio seating for the residents. Air/Heating: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: Bedrooms are for 0 ambulatory, 5 non-ambulatory, and 1 bedridden resident. Bedrooms will accommodate 6 residents with 4 private rooms and 1 shared room accommodating two clients. Bedrooms 1 and 5 have a full bathroom. Bedrooms Staff: Single story building located in back yard designated for awake-staff. Continued on LIC809-C Bathrooms: All bathrooms have a working toilet, wash basin, walk in shower. Linens & Hygiene Supplies: Adequate supply of linen stored in each individual bedroom in storage closet. 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 stored in the kitchen with surplus goods stored in attached garage. Smoke Detectors: Smoke detectors and carbon monoxide alert systems are hardwired, were tested and found operational. Appliances: Electric four-burner stove, single oven, 1 refrigerator, microwave, washer, and dryer are clean and noted to be operational. Toxins: All and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to residents are stored and locked underneath kitchen sink and in attached garage. Water Temperature: Tested and recorded maintained at a comfortable temperature and the water temperature measures 120.2 Fahrenheit degrees in resident restrooms and common bathroom. Continued on LIC809-C Medications, First-Aid Kit & Book: Medication and First Aid kit stored in locked medication storage closet. Resident & Staff Files : Records will be kept in locked medication storage closet. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the resident's use, commensurate with the plan of operation. Fire clearance: Was approved on 10/20/22. Component III: Component three waived during visit. Applicant is Licensee/Administrator of other licensed facility. Applicant was reminded that it is required to notify LPA, within 5 business days of admitting the first resident. This notification may be done by phone, email or fax. 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.