Pre-licensing visit·February 4, 2022

Licensing Program Analyst (LPA), Natasha Persaud conducted a Prelicensing inspection. A Change of Ownership application to operate a Residential Care Facility for the Elderly was received on 11/12/21. The facility was approved to care for six (6) elderly residents; five (5) Non-Ambulatory, and one (1) Bedridden. LPA was greeted and allowed entry into the facility by Licensee, Karen Kanan. Structure - The facility is a single story structure with 6 bedrooms, and 3 bathrooms. There is an outdoor covered area for resident use. No bodies of water were observed. B edrooms Residents - Rooms #1-#6 may be used for Non-Ambulatory and bedridden; Only one (1) bedridden at a time. Bedrooms Staff - There is no staff bedroom. Bathrooms - All bathrooms have a working toilet, sink, grab bars and tub/showers with non-skid mats. Linens & Hygiene Supplies - Adequate supply. Emergency Phone Numbers, Exit Plan and Required Postings - Posted. Smoke Detectors and Carbon Monoxide Detectors- Interconnected and hardwired. Appliances - Stove burners, oven, microwave, washer, and dryer working. Toxins - Stored in a locked cabinet. Water Temperature - Measured at 118 degrees F. Medications- Centrally stored and locked in a cabinet First-Aid Kit - Stored in garage. Resident & Staff Files - Located in a locked cabinet. Activities - Adequate supplies. The facility has board games, and materials for the resident's use. Fire clearance - Approved on 12/23/21. Component III - Conducted at the Pre-Licensing visit. Information provided about how to operate the facility within substantial compliance. All items reviewed during the visit are in compliance. Pre-Licensing is complete and this facility has no deficiencies . Facility appears to be ready for licensure pending final review. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) was provided to Licensee, Karen Kanan whose signature below confirms receipt of these rights.