Pre-licensing visit·September 28, 2022

On 09/28/2022, Licensing Program Analyst (LPA) Sarena Keosavang conducted an Prelicensing inspection. LPA met with Administrator, Alfonsus Hardosubroto, and explained the purpose of the visit. LPA were screened by Administrator prior to entering the facility. LPA wore a surgical mask while at the facility. The facility has six (6) bedrooms and three (2) bathrooms. LPA observed the common areas, kitchen area, bedrooms, and bathrooms. LPA observed knives/ sharps area were locked in the kitchen cabinets. Toxic and cleaning supplies are locked underneath the sink cabinet located in the kitchen. LPA observed food supplies of non-perishables for a minimum of one week and perishable foods for a minimum of two days. LPA observed required furniture, and lighting throughout the facility. Bathrooms are clean, sanitary, and in good repair. The hot water temperature was measured in the kitchen at 106 degrees Fahrenheit. First aid kit was completed with bandages, tweezers, scissors, and thermometer. LPA observed centrally stored medications area were locked and inaccessible. Outdoor passageways were free of obstruction. LPA observed one (1) fire extinguisher, smoke detectors, and carbon monoxide detectors in the facility. Licensing complaint poster are posted as required. Component III presentation conducted with administrator. LPA observed that the facility is ready to be licensed. This report will be submitted to the Central Applications Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required. An exit interview was conducted with administrator and a copy of this report will be provided to the facility via email.