Pre-licensing visit·July 8, 2024

Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 9:00 AM, LPA met with Kathleen Hyland. An initial application for Change of Ownership to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 5/3/2024 for a total capacity of fourteen (14); ten (10) non-ambulatory and four (4) bedridden residents. Fire clearance was granted on 05/23/2024. LPA Delgado observed the following: Structure: Facility was a one-story building with two (2) additional structures, thirteen (13) resident bedrooms, eight (8) resident bathrooms, living room, dining area and kitchen. There is no garage; one structure for food storage, personal hygiene storage and second structure is the laundry room and one (1) resident shared room. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control the main building. Bedrooms: Each resident bedroom #101, #102, #103, #104, #105, #108, #109, #110, #111 and #112 will accommodate any non-ambulatory resident, bedrooms #106, #107 and #400 A&B will accommodate bedridden residents. 12 resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting. All resident rooms are furnished with a TV. (CONTINUED ON LIC 809C) (Continued from Page 1) Bathrooms: The eight (8) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 10:15 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 121. degrees Fahrenheit with warning labels. Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked cabinet located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located in a separate structure. Laundry detergents and cleaning supplies were observed in separate structure away from residents. Living/Family room: There was a living room with seating for clients and a TV. Linens and Hygiene Supplies: An adequate supply of linens was stored in the personal hygiene structure. Yards/Outside: Patio table and chairs were observed in the outdoor area. There was a gate on the North side with a self-latching lock. All outdoor pathways were free of obstructions. Emergency Phone Numbers, and Exit Plan: Facility sketch were observed posted at all exits. Obudsman poster and Let-Us-No poster observed. (Continued on Page 3) (Continued from Page 2) General items: Five (5) fire extinguishers were charged and located in the kitchen, hallway, 400 structure, break room and laundry room. Three (3) smoke alarms and four (4) carbon monoxide detectors were tested and were observed to be in working order except for one (1) carbon monoxide detector in 400 structure. Three (3) structures are maintained by Security Signal Devices monitors the alarm panel and SBRC Fire Protection that provide fire protection and life safety services for the fire sprinklers and other services. Client records will be stored in a locked cabinet in the Office. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Emergency water supply and 72-hour emergency food supply was observed. Component III will be completed on July 25, 2024 at Riverside RO. There are no firearms stored and no bodies of water observed. Pre-Licensing is incomplete and the following corrections to be resolved by 8/05/2024: obtain new flooring obtain door alarms for 400 structure, room #106, #107 obtain keylock for cleaning supplies under kitchen sink obtain cover phone line obtain paper towel holder organized overflow of medications repair carbon monoxide detector in 400 structure repair cabinets doors inside the kitchen repair exterior window screen for 400 structure repair broken drawer in laundry room repair base shelf under kitchen sink (Continued on Page 3) (Continued from Page 3) replace dressers in 400 structure replace ceiling fan light bulb for room #111 replace broken window blinds replace fan exhaust screen for stove remove missing toilet paper brackets remove missing towel bar brackets remove bottom latch on exit door set-up room for second resident in 400 structure An exit interview was conducted with Kathleen Hyland and a copy of this report was given.