Pre-licensing visit·November 25, 2025

Licensing Program Analyst (LPA) Kimberly Lyman made an announced visit to conduct a pre-licensing inspection. LPA identified herself and discussed the purpose of the visit with Administrator/ Licensee Amy Cole. An initial application to operate a Residential Care Facility for the Elderly was submitted to Community Care Licensing on 04/01/2025 for a capacity of five non-ambulatory and one bedridden resident. Upon entry, facility appears clean, safe and sanitary. Facility has all required postings including personal rights, theft and loss policy, and the complaint poster. Administrator Amy Cole has an administrator certificate expiring on 06/17/2026. LPA Lyman along with Administrator Cole toured the facility at 8:10 AM and observed the following: Structure: Facility is a two story home with five bedrooms, two restrooms, living room, sitting area, dining room and kitchen on first floor and staff room on second floor as well as a dark blue exterior. Living Room/ Dining Room : Adequate seating is available in the dining room and living areas. Bedrooms Residents: Rooms are single and double occupancy. All rooms are equipped with appropriate lighting, chair, night stand and ample storage space, Exit doors have auditory alarms. Linens & Hygiene Supplies: Facility has ample bedding and towels in supply as well as hygiene supplies. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as paper towels and soap. Emergency Phone Numbers and Exit Plan: Posted in the entrance of the facility. Food Service: LPA observed the kitchen and serving area. Facility to obtain food supplies upon accepting residents. Smoke Detectors: Smoke detectors and carbon monoxide detectors tested operational during today's visit. Fire extinguishers are fully charged. Appliances: Kitchen and laundry appliances are clean and operational. CONTINUED ON LIC 9099C DATED 11/25/2025 Toxins / Sharps : Facility has secured areas for toxins and sharps. Water Temperature: Tested and recorded between 105 and 106.3 degrees F. in facility restrooms. Emergency Supplies: LPA observed ample emergency food and water as well as emergency supplies. Medications, First-Aid Kit & Book: First aid kit observed contained all required items including tweezers, scissors and thermometer as well as a first aid manual. Medications to be stored in a locked cabinet. Resident & Staff File: Records are to be stored in a locked cabinet. Reading Material, Games, and Equipment: LPA observed a posted activity schedule with activities such as games and exercise. Outside areas : LPA observed an outside area with ample shaded seating. Fire Clearance: Approved for five non-ambulatory and one bedridden resident on 04/22/2025. Component III conducted during the visit. Facility is ready to be licensed. Exit interview conducted and a copy of this report was left at the facility.