Pre-licensing visit·September 2, 2025

On 9/2/2025, Licensing Program Analyst, Arvin Villanueva (LPA) arrived unannounced at this facility to conduct the pre-licensing inspection. LPA met initially met with staff on duty (S1) and explained the purpose of the visit. The Licensee, Adilina Tuiloma, and Administrator Tevita Kaloulasulasu, were notified of the visit. The Administrator arrived at 11:15 am. The Licensee arrived at around 12:30pm. Overview : The facility is a single-story home situated in a residential neighborhood. It will be licensed to accommodate up to six elderly residents. According to the fire clearance, Bedrooms #1 through #6 are approved for non-ambulatory residents. Bedroom #7 has been designated as the staff room. The facility does not have clearance for bedridden residents, delayed egress systems, or locked exterior gates. Facility submitted hospice waiver request for 1 resident. Initial Observation: Upon arrival LPA was greeted by staff on duty (S1). Present during this visit were 5 residents in care, with one staff on duty (S1). One staff from an outside agency was also present providing care for one resident. Room temperature was at 74 degrees Fahrenheit upon arrival. Physical Inspection : Areas inspected include, but not limited to, the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA inspected 5 of 6 resident bedrooms. LPA measured the hot water temperature in the 3 of 3 bathrooms to be between 109 and 110 degrees Fahrenheit. All resident bathrooms were observed to be in good repair at this time. Advisory was provided to install grab bars in one of the bathrooms. Advisory was provided to ensure the fire door remain close at all times. Advisory was provided to update their facility sketch to include the fire door and location of their shut off valves. {809-1} Fire extinguisher was observed in the kitchen area, and it was last inspected on 3/26/2025. Smoke and carbon monoxide detectors were observed throughout. One carbon monoxide detector was tested and found operable at this time. Three smoke detectors were tested and found operable. In the kitchen area, LPA observed at least seven day non-perishable and two day perishable food supplies. Kitchen refrigerator and freezer were maintained at regulatory temperature. Pantry is located at the resident hallway and was observed to be stocked with non-perishable food items. Medication cabinet was observed to be locked and not accessible to residents in care. Toxic materials, cleaning supplies, sharp objects and other dangerous items were observed to be in locked storage. Outdoor area was inspected. LPA observed outdoor furniture for resident use. Emergency walkways were observed to be unobstructed. Facility has one exit gate and was observed to be in good condition at this time. Component III was conducted with the Administrator. Based on today’s inspection, this Pre-Licensing is complete and this facility has no deficiencies at this time. Exit interview was conducted and a copy of the report was provided upon exit. {809-2}