Pre-licensing visit·November 2, 2021

Licensing Program Analyst (LPA) Christina Valerio arrived at the facility to conduct an announced pre-licensing visit. LPA Valerio introduced herself and discussed the elements of the pre-licensing visit with Administrator Elizabeth Cruz. LPA Valerio was screened for COVID-19 symptoms and temperature taken prior to being allowed entry into the facility. LPA was also asked to wash hands prior to being allowed entry. Facility staff confirmed no resident or staff have been observed to have any signs or symptoms of COVID-19 in the last 10 days. The facility has a fire clearance for a total of 61 residents, of which 51 non-ambulatory residents and 10 bedridden residents. The facility has an approved hospice waiver on file. Observed there are 46 residents in care for Assisted Living and Memory Care. The facility has an approved LIC 808 mitigation plan on file and uploaded into FAS. LPA toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. The facility has two wings, one for assisted living and one for memory care, and exterior area. The memory care unit is secured by a locked door system. The exterior area has a gazebo and a sitting area for outdoor visits. LPA observed the area where the staff and resident files will be locked and readily available for review. Files were organized and had necessary documents. Emergency disaster plan and necessary signage posted and available. Facility has a 30-day supply of face shields, gowns, N95s, surgical masks, hand sanitizers, and sanitizing wipes located in the storage room. Facility common areas were clean with no sticky floors. First aid kits and emergency supply of food were observed to be fully stocked. LPA observed no obstruction of emergency exits inside or outside of facility. Continues on LIC 809-C... Page 1 of 2 Continues from LIC 809... LPA Valerio observed the commercial kitchen area, outside storage pantry, dining area, 4 resident bedrooms and bathrooms, storage areas, activity room, medication room, and office areas. The kitchen was clean and organized. There is a locked shed located outside the facility near the exit of the kitchen that is used to store the emergency supply of food and water. LPA observed area where food supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days are maintained on the premises. All items outside of the original packaging were dated. LPA observed resident rooms on the Assisted Living and Memory Care side. Resident bedrooms observed to have necessary furniture. Resident bedrooms are furnished with a bed, chair, night stand, personal dresser, and closet space. Resident bathrooms observed to have non-skid mats, soap, paper towels, hand sanitizers, and garbage cans. Resident bedrooms were clean and did not have an odor. Hand sanitizer is available throughout the facility. COVID-19 informational, hand washing, and social distancing signs are posted throughout the facility. All emergency exits have appropriate signage. Cleaning supplies were secured and locked in the storage room. Smoke detectors and carbon monoxide detectors were noted and functioning properly. Hot water temperature in resident's bathroom measured at 118.2*F , 112.7*F, 112.4*F, 111.9*F in 4 bathrooms, which is within regulatory range of 105 *F and 120 *F. Fire extinguishers were up to date with last check on 06/18/2021. A Component III was completed during the visit with the Administrator Elizabeth Cruz. Administrator had no further questions. Pre-Licensing is complete and this facility has no deficiencies. Exit interview held, and a copy of the report was given. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed.