Pre-licensing visit·July 24, 2025

Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 8:30 AM, LPA met with Licensee/Administrator Korey Davis. An initial application to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 10/01/2024 for a total capacity of five (5) non-ambulatory and one (1) bedridden residents. Fire clearance was granted on 12/21/2024. LPA Delgado observed the following: Structure: Facility was a one-story house with three (3) resident bedrooms, three (3) resident bathrooms, living room, dining area, kitchen, and office. There was an attached two (2) car garage in the front of the house. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control entire house. Bedrooms: Each resident bedroom #2, #3 and #4 will accommodate any non-ambulatory resident, Licensee has designated bedroom #2 will accommodate bedridden resident however #3 and #4 can accommodate as well per Fire Clearance. Three (3) resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, inadequate lighting, and an operable smoke alarm; additional beside tables needed. Bathrooms: The three (3) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 10:00 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 112 degrees Fahrenheit. (CONTINUED ON LIC 809C) (CONTINUED FROM PAGE 1) Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a wood locked box 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 inside the home. Laundry detergents and cleaning supplies were observed in garage away from residents. Living/Family room: There was a living room with seating for all clients and TV. Linens and Hygiene Supplies: An adequate supply of linens was stored in a cabinet in the main hallway and hygiene supplies stored inside a storage inside the garage of the residence. Yards/Outside: Patio table with three (3) chairs were observed in the backyard; additional chairs are needed, umbrella is present for shade. There was a gate on the East side of the property with a self-latching lock. All outdoor pathways were not free of obstructions. Emergency Phone Numbers, and Exit Plan: Facility sketch were observed posted in the main hallway. Obudsman poster and Let-Us-No poster observed. General items: Two (2) fire extinguishers were charged and located in the kitchen and hallway. Eight (8) dual smoke/carbon monoxide alarms and one (1) carbon monoxide detectors were tested and were observed to be in working order. Client records and staff records will be stored in a locked cabinet in the garage. First Aid kit with required components, First Aid manual not observed and locked area for medication storage was observed in the kitchen. LPA observed a facility phone and it has to be connected to service. Emergency water supply was not observed however the required 72-hour emergency food supply was not discernible from the regular food supply. LPA did not observe no bodies of water and no firearms will be stored at the home. LPA confirmed Component III was completed on July 8, 2025 at Riverside RO. (CONTINUED ON PAGE 3) (CONTINUED FROM PAGE 2) Pre-Licensing is incomplete and the following corrections to be resolved by 08/07/2025: fix bedframe for bed in bedroom #4 obtain a separate 72-hour emergency food supply obtain separate emergency water obtain bedside table for bedrooms #2, #3, #4 obtain lamp for bedrooms #2, #3, #4 obtain additional emergency lightning obtain and post visiting policy obtain PPE supplies obtain a lock door knob for laundry room obtain First Aid Manual 11th Edition obtain a landline number post non-discrimination notice remove debris from walkway in the backyard remove personal items from bedrooms An exit interview was conducted, and a copy of this report will be emailed and a confirmation receipt will be requested.