Pre-licensing visit·June 4, 2025

Licensing Program Analyst (LPA) Jenifer Tirre visited this facility for the purpose of conducting a Pre-Licensing evaluation. Facility is a two story residential home. LPA Tirre along with Applicants Ricardo Banos and Flormine Resurreccion toured facility at 8:15AM and observed the following: Fire clearance approval was received on 2/3/2025 for Six (6) Non Ambulatory residents , one (1) of which can be Bedridden. Fire Clearance is approved for residents residing on first floor. Second floor is not accessible for residents and will be used as live in bedrooms for staff Structure: Facility is a two story, 6 resident private bedrooms located on first floor and two live in staff bedrooms located on second story. Facility Has three (3) full bathrooms with attached two car garage and white exterior. Living Room/ Dining Room : Adequate seating is available in the dining room and living room. Bedrooms Residents: All Residents bedrooms meet Licensing requirements and has required furnishings Bathrooms: All resident bathrooms have a working toilet, wash basin, and bathtub/shower as well as grab bars and non-skid surface mats in the shower. Linens & Hygiene Supplies: Facility has adequate supply of linens, blankets, towels as well as secured hygiene supplies. Emergency Phone Numbers and Exit Plan: Facility has Emergency Plan posted on wall and required postings. 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: Home has combination Smoke detectors and carbon monoxide detectors which are centrally wired and tested operational. Fire extinguishers are mounted and charged. Facility has 2 extinguishers. Facility has audible alarms on all exit doors and perimeter gate. CONTINUED ON 809C Appliances: Gas stove, refrigerator and microwave are operational. Toxins : LPA observed cleaning supplies and sharps secured in storage area and closet. Water Temperature: Tested and recorded between 109.2 to 119.1 degrees F. in facility bathrooms. Reading Material Games, and Equipment: facility has puzzles, games, books and music therapy being provided. Facility has tablet with Internet access available for residents use. Medications, First-Aid Kit & Book: Facility has first aid kit present at the facility along with First Aid Manual. Facility has a secured location for medications and facility files. Backyard: LPA observed the facility perimeter is secured by walls with a self latching gate on both sides of facility as required. Facility has audible alarms on perimeter gates. LPA observed shaded outdoor seating. Administrator's Certificate for Ricardo Banos observed on wall expiring 1/11/2026. Component III Orientation was conducted during visit. No deficiencies noted during todays visit. The pre-licensing visit has been completed. An exit interview was conducted with Administrator and a copy of report was left at facility