Pre-licensing visit·December 21, 2021

Licensing Program Analyst (LPA), Kristina Ryan conducted an announced Pre-Licensing inspection. LPA identified herself to Administrator, Shanel Pronovost., and explained the purpose of the visit which was to evaluate Title 22 compliance for a Change of Ownership application. The facility plans to serve elderly residents, ages 60 and over. The Fire Clearance was granted on July 16, 2021. Facility is approved for 6 residents, 4 of whom can be non-ambulatory. Facility is approved for 2 bedridden residents. An inspection of the facility was conducted inside and out. All resident rooms were observed. Bathrooms are equipped with toilets, and hand-washing and bathing facilities are sanitary and in operating condition. LPA was unable to check the water temperature due to the water temporarily being turned off by the city due to a broken pipe on the street. .Administrator provided a water temperature log for LPA to review. Last temperature recorded on 12/20/2021 was 113.5 Fahrenheit. Each room was set at a comfortable temperature. All lighting fixtures and facility windows were operable and in good condition. Outdoor and indoor passageways were free from obstructions. Fire extinguishers were affixed with current tags. Smoke and carbon monoxide detectors were present and operational. There were no pools or other bodies of water observed on the premises. Locked cabinets and storage areas were identified to store toxic substances, knives, and medication. Hazardous items were stored such that they were inaccessible to residents. Per Administrator Pronovost, no weapons or ammunition are or will be stored at the facility. LPA reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC 808) with Ms. Pronovost. LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, staff retention and essential health and safety. LPA observed facility accommodations including food supplies, medication storage, first aid kit as well as toiletries and linens. Required CCLD postings were present. LPA reviewed a sampling of staff and resident records. Resident records that were reviewed included admissions agreements, physician's reports, and pre-placement appraisals. Staff records were reviewed for criminal background clearance, criminal record statement, and first aid/ CPR training. The administers Administrator Certification expires September 30, 2023. Component III was reviewed with administrator. The application will be sent to the Centralized Application Bureau for final review and approval. An exit interview was conducted with Administrator, Shanel Pronovost. A copy of this report, along with the Licensee Rights (9058 01/16) was emailed to Ms. Pronovost at the conclusion of the visit, an electronic response confirms the receipt of these documents.