Pre-licensing visit·March 9, 2023

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 11/22/2022. Structure: The facility is a one story house with an attached garage with 5 resident bedrooms, 5 full bathrooms, 1 living room, and a kitchen. The resident’s bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a large back yard with an exit walkway on each side of the house with covered seating for the residents. Air/Heating: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: Bedrooms will accommodate 6 residents with 4 private rooms and 1 shared room accommodating two resident's. 4 Bedrooms have a full bathroom. Bedrooms Staff: There is a bedroom designated for live in 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 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 stored in the kitchen with surplus goods stored in the garage. Smoke Detectors: Smoke detectors and carbon monoxide alert systems are hardwired, were tested and found operational. Appliances: Gas four-burner stove, single oven, 2 refrigerators (one in attached garage), 1 freezer, 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 in garage. Water Temperature: Tested and recorded maintained at a comfortable temperature and the water temperature measures 105.2 – 106.8 Fahrenheit degrees in resident and common bathrooms. Continued on LIC809-C Medications, First-Aid Kit & Book: Medication and First Aid kit/book stored in locked closet storage. Resident & Staff Files : Records will be kept locked with medication closet storage. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the client's use, commensurate with the plan of operation. Fire clearance: Was approved on 01/24/2023. Component III: Component three waived during visit. Applicant is Licensee/Administrator of other licensed facilities. 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.