Pre-licensing visit·October 10, 2025

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 Tirre along with Administrator Amelia Morales and Licensee Theresa Kholoma toured facility at 9:15AM and observed the following: Fire clearance approval was received on 09/22/25. Structure: Facility is a one story, six private Resident bedrooms, two 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 meet Licensing requirements. Bathrooms: All resident bathrooms have a working toilet, wash basin, and 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 and evacuation plan posted on wall. Food Service: Facility has two day perishables as well as seven 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. Fire extinguisher is mounted and charged. Facility has 1 extinguisher. Facility has audible alarms on all sliding/exit doors. Appliances: Gas Stove and refrigerator are operational. Toxins : LPA observed toxins secured in laundry storage area and underneath kitchen sink.. Water Temperature: Tested and recorded between 115.5 to 116.4 degrees F. in facility bathrooms. Reading Material Games, and Equipment: Facility’s plan is to have a activities coordinator visit twice a week for exercises and games. Facility has puzzles and board games available. Medications, First-Aid Kit & Book: Facility has first aid kit present at the facility. Facility has a secured location for medications and facility files. CONTINUED ON 809C Backyard: LPA observed the facility perimeter is secured by a fence in front yard and wall with a self latching gate on side of facility as required. LPA observed shaded outdoor patio seating. Administrator's Certificate observed for Amelia Morales #6016466740 expiring October 22, 2027. Component III Orientation was conducted during this pre-licensing visit and guidelines were reviewed with Administrator Morales and Licensee Kholoma. The pre-licensing visit has been completed. An exit interview was conducted with Administrator Amelia Morales and a copy of report was left at facility