Pre-licensing visit·January 20, 2022

Licensing Program Analyst (LPA) Sabel Martinez, conducted a scheduled Pre-licensing inspection to observe the physical plant for compliance and conduct Comp III. The facility is undergoing a change of ownership. The fire department completed their inspection 11/3/21. Facility is approved for six (6) residents. Bedroom one (1) is approved for ambulatory only. Bedrooms 2,3,4,5, and 6 are approved for non-ambulatory. LPA was greeted by Administrator Mark Melton and Jean Melton. LPA was granted entry after identifying himself and disclosing the purpose of the visit. An overall tour of the facility was conducted inside and out. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other written requirements that are most relevant to protecting the health of residents in care and staff, including in the area of infection control practices. LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff and residents; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE. The facility is in compliance with and has implemented infection control practices as outlined in its LIC 808. LPA discussed with the applicant continuing operation requirements, record keeping, reporting requirement and physical plant compliance. The Pre-licensing and Component III were completed on today's date. Facility is ready for Licensure pending management approval. This is a change of ownership application and there are five (5) residents currently in care. An exit interview was conducted with Administrator Mark Melton, and Jean Melton. A copy of this report along with Applicant/Appeal Rights (LIC9058 01/16) were emailed to Administrator Mark Melton. An electronic email read receipt confirms the documents were received.