Pre-licensing visit·July 1, 2025

On July 1, 2025, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct a Pre-Licensing visit following a change of ownership. Upon arrival, LPA was greeted by the applicant, Tevi Kaloulasulasu, who will also serve as the facility administrator. LPA explained the purpose of the visit and proceeded with a brief interview with the applicant Tevi. The census is five. The facility has a fire clearance for 6 non-ambulatory residents only. At this time, the facility is not approved to accept or retain any residents who are bedridden, nor does it have an approved hospice waiver. According to applicant Tevi, the facility will have a live-in staff and will continue to provide 24-hour care, seven days a week. LPA conducted a tour of the facility, inspecting both the interior and exterior, common living spaces, resident bedrooms, bathrooms, the kitchen, and other areas intended for resident use were all toured. It was observed that the fu rniture and furnishings were adequate and in good condition to meet the needs of the residents at this time. The garage was inspected and observed that the laundry is kept in the garage and LPA observed that laundry detergent, bleach, and other cleaning supplies were safely stored and inaccessible to residents. All required postings were visible throughout the facility. Smoke and carbon monoxide detectors were tested and found to be in good working condition. A fire extinguisher, located in the kitchen and was observed to be serviced and valid until 11/27/2025. LPA toured all five resident bedrooms, as well as one caregiver room. All furniture and furnishings appeared to be in good repair. During the bathroom inspections, hot water temperatures were taken and the hot water temperature measured 116.1 degrees Fahrenheit which is within the required regulation of 105 to 120 degrees Fahrenheit. Continued LIC 809-C In the kitchen, LPA observed an adequate supply of food at least two days’ worth of perishable and seven days’ worth of non-perishable items sufficient to meet the residents’ needs. Kitchen knives were securely locked and inaccessible to residents. The facility’s internal temperature was observed to be 76 degrees, and a public telephone was available in the kitchen for residents’ use. The linen closet, located in the hallway, contained sufficient supplies of clean towels, blankets, and bed linens. Medications were stored in a locked centralized cabinet located in the front entry closet. Together with the applicant Tevi and caregiver Ratumanoa, the resident’s medications with the medication logs were reviewed, which were found to be complete and accurate. File reviews were conducted for five residents and one staff member, and it was complete. The first aid kit was present and contained the required items. Outside the facility, the physical plant was in good repair, free from hazards. The perimeter fencing was secure, and all gates were in working condition. During today’s visit, LPA Lee observed that the interior layout of the facility does align with the submitted and approved facility sketch. LPA Lee also advised that no changes to the interior or exterior of the facility should be made without prior notification and approval from both the department and the fire department. LPA Lee discussed and recommended the Technical Support Program (TSP) to the applicant, Tevi. The applicant expressed interest in being referred to the program. LPA Lee advised that the referral to TSP will be completed. Based on the observations made during the visit, the applicant has passed the Pre-Licensing component. Component III was also reviewed with the applicant. LPA will notify the Central Application Bureau (CAB) that the Pre-Licensing visit has been completed and passed. An exit interview was conducted, and a copy of the report was provided to the applicant Tevi.