Pre-licensing visit·January 18, 2022

*THIS IS AN AMENDED REPORT Licensing Program Analyst (LPA) Amy Goldenberg conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Unit (CAU) on 08/20/2021 for a total capacity of four (4) non-ambulatory residents and one (1) bedridden resident in bedrooms 1 or 3 only. Fire Clearance was granted 09/15/2021 LPA Goldenberg observed the following: Structure: Facility is a two (2) story house with three (3) resident bedrooms on the first floor, two bathrooms, living room, dining area, and kitchen area. Heating/Cooling System: Central heating and air conditioning systems. Bedrooms: Each resident bedroom will accommodate Non-Ambulatory clients. All bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm. Bathrooms: Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Water temperature measured by LPA at 108 F. Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies and knives/sharp instruments were secured in a locked cabinet and/or drawer. There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals. Living/Family room: Furnished with safe and adequate seating and furnishings. All items appear to be in good repair. Yards/Outside: The back was completed was a patio with adequate covered area for providing shade. There were no obstructions. There is a pool secured with a locked perimeter. Garage: Laundry area with washer and dryer were located near the garage entrance. Laundry detergents and cleaning solutions were secured behind a locked cabinet door. Garage was organized and free of obstructions. Additional freezer and refrigerator are located in the garage. Emergency Phone Numbers, and Exit Plan: Let-Us-No poster, Ombudsman poster and clients rights are posted. General items: The facility phone was verified to be operational by LPA. LPA reviewed COMPONENT III with the applicant during this Pre Licensing Inspection. This facility physical plant is prepared for licensure at this time.