Pre-licensing visit·October 25, 2024

Licensing Program Analyst (LPA) Jenifer Tirre visited this facility for the purpose of conducting a Pre-Licensing evaluation. Facility is a single story residential home. LPA along with Licensee Maricel Nepomuceno and Administrator Justin Duclayan toured facility at 3:45 PM and observed the following: Fire clearance approval was received on 09/17/24. Structure: Facility is a one story, 6 bedroom (4 private Residents bedrooms, 1 shared resident bedroom and 1 staff room area) 5 full bathrooms house with detached garage and a beige exterior. Living Room/ Dining Room : Adequate seating is available in the dining room and living room. Bedrooms Residents: All Residents bedrooms meet Licensing requirements. Bathrooms: All resident bathrooms have a working toilet, wash basin, and bathtub/shower as well as grab bars and 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 posted on wall and operating landline Food Service: Facility has 2 day perishables as well as 7 day non-perishables in the pantry/ refrigerator, as well as emergency food and water supply. Smoke Detectors: Smoke detectors and carbon monoxide detector are centrally wired and were tested operational. Facility has 3 Fire extinguishers which are mounted and charged. Facility has audible alarms on all sliding/exit doors. Appliances: Electric Stove and refrigerator are operational. Toxins : LPA observed toxins secured in laundry storage area. Sharps are secured in drawer. Water Temperature: Tested and recorded between 108.5 to 111.7 degrees F. in facility bathrooms. Reading Material Games, and Equipment: facility does exercises, puzzles, bingo and has activity directors. Medications, First-Aid Kit & Book: Facility has first aid kit 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 both sides of facility as required. LPA observed shaded outdoor seating and golf green area. Backyard has outside covered Jacuzzi that is non operational. CONTINUED 809C Administrator's Certificate on file for Justin Duclayan observed on wall effective 10/3/2024- 10/2/2026 Component III Orientation was waived during this pre-licensing visit due to licensee presently operating several facilities. No deficiencies noted during todays visit. The pre-licensing visit has been completed. This location is ready for licensure. An exit interview was conducted with Administrator and a copy of report was left at facility