Pre-licensing visit·May 3, 2024

Licensing Program Analyst's (LPA's) Jenifer Tirre and Michael Tea visited this facility for the purpose of conducting a Pre-Licensing evaluation for change of location. Facility is a single story residential home. LPA's along with Licensee/Administrator Tin Le toured facility at 2:10 PM and observed the following: Fire clearance approval was received on 03/14/24. Structure: Facility is a one story, 4 bedroom (3 Residents bedrooms and 1 live in staff bedroom) 2 bathroom house with attached garage and a white exterior. Living Room/ Dining Room : Adequate seating is available in the dining room and living room. Bedrooms Residents: All Residents bedrooms need additional furnishings such as beds. Bathrooms: All resident bathrooms have a working toilet, wash basin, and bathtub/shower as well as grab bars. One of two restrooms has a non-skid surface in the shower. Linens & Hygiene Supplies: Facility has adequate supply of linens and towels. Emergency Phone Numbers and Exit Plan: Facility has Emergency Plan. Food Service: Facility does not have 2 day perishables & 7 day non-perishables in the pantry/ refrigerator, as well as emergency food and water supply. Smoke Detectors: Smoke detectors/ carbon monoxide detector are centrally wired and were tested operational. Facility has one fire extinguisher which is mounted and charged. Facility has audible alarms on entry/exit doors. Appliances: Gas Stove and refrigerator are operational. Toxins : LPA observed toxins secured in storage area.. Water Temperature: Tested and recorded at 106.7 degrees F. in facility bathrooms. Reading Material Games, and Equipment: facility did not have activity supplies at time of visit. Medications, First-Aid Kit & Book: Facility did not have first aid kit or First aid manual present at the facility. Facility has a secured location for medications and facility files. Backyard: LPA observed the facility perimeter is secured by wall with a self latching gate on right side of facility as required. LPA observed shaded outdoor seating. Component III Orientation was waived during this pre-licensing visit due to Administrator presently operating several facilities. CONTINUED ON 9099C Licensee to address the following corrections by 5/6//2024: Facility to provide a secure door knob/lock on staff room Facility to provide First Aid kit & First Aid Manual Facility to provide a tablet device with internet for resident use Facility to provide Adequate perishable & non- perishable foods Facility to provide Emergency food & water supply Facility to provide Department postings Facility to provide skid proof mat for restroom 1 Facility to provide a updated Fire Extinguisher tagged by Fire department Facility to provide audible alarms on all sliding doors Facility to provide a land line phone on premise Facility to provide call buttons for room The facility is not ready to be licensed. Licensee to contact LPA when corrections are complete. An exit interview was conducted with Licensee and a copy of this report was left at the facility.