Pre-licensing visit·July 10, 2025

On 7/10/25 at 8:50 am LPA Noel Wolf Petersen arrived announced to conduct the facility prelicensing inspection, the LPA met with the administrator and explained the purpose of the visit. Shield Care homes is seeking licensure as a 6 bed RCFE for six nonambulatory residents. A inspection of the physical plant was conducted, including but not limited to the bedrooms, bathrooms, kitchen, storage areas, common areas, exteriors, and evacuation routes. The facility is clean and the furnishings are in good repair. Bedrooms have required furniture. The bathrooms hardware is functional and the water temperature was measured 117*F. The telephone has is connected and has the ability to be reasonably private, 2 days of perishable and 7 days of nonperishable food is present, the LPA pointed out some dented cans that the administrator removed. The toxics sharps and medications have the ability to be stored locked; the LPA observed 10 sticks of caulk and two clorox grout cleaner stored in an accessible manner; the administrator moved them to locked storage. The common areas have indoor activities(puzzles games, books, tv) available and there is adequate space outside for activities(the facility has a dog park immediately next to the property), there are no tripping hazards and traffic areas are unobstructed. the required posters are displayed in the correct dimension, including the ombudsman, the federal work rights, personal rights, facility sketch with evacuation routes, and administrator certification. The first aid kit has all required items. Smoke and CO2 hybrid alarm is functional. The fire extinguisher was dated 7/10/25. Continued on C Page. 1 staff interviews were conducted. The administrator documents were reviewed including but not limited to the plan of op(grievance, sign-in/out, reporting requirements, refund, eviction, and visitation policy), sample admissions agreement, infection control plan, evacuation control plan, surety bond. liability insurance. The comp III presentation was given, a copy of the report was read and given to the administrator. An exit interview was conducted.