Pre-licensing visit·November 8, 2023

Licensing Program Analyst (LPA) Jenny Olson arrived at the facility announced at 2:30 p.m. to conduct a pre-licensing inspection. The LPA met with Amelita Aquino, Administrator. This is a new application. The current capacity is for six (6) residents, the facility currently has zero (0) residents. The fire clearance was granted on 10/17/2023; in which bedroom #1, #4, and #5 was cleared for non-ambulatory, and bedrooms #2,and #3 were cleared for ambulatory residents. There is one staff room. Applicant successfully completed Component II on 10/31/2023. Component III was completed during the visit. At 3:00 p.m., the LPA toured the physical plant areas inside and outside with applicant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN : Kitchen knives are stored locked and inaccessible in the drawer next to the stove. The supply of perishable and nonperishable food is adequate. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. The gas was not turned on and will be turned on Friday 11/10/2023. Applicant will send LPA water temperature readings. BEDROOMS : There are seven (7) bedrooms in the facility; the facility has five (5) bedrooms for resident use, and two (2) staff room. The staff room will be kept locked. Lighting in the rooms appeared adequate. All resident rooms were set up with beds, nightstands, lamps, chests of drawers, chairs, and closet space. BATHROOMS : There are four (4) full bathrooms one in the main hallway next to the kitchen, one in the back of the house, one in the master (Room #1) and one upstairs in the staff room. The showers are equipped with nonskid mats. Grab bars were observed in the bathrooms. MEDICATIONS : Medications will be in a locked cabinet located in the facility kitchen and will be locked and inaccessible to residents in care. The first aid supplies were complete, including a first aid manual. Continued on LIC809-C COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment in the living room area. The facility smoke alarm system is hard wired; the smoke detectors and carbon monoxide were operable at the time of the visit. There is (1) fire extinguisher which was fully charged and last serviced on 09/26/2023. There is a functioning telephone on the premises. Emergency exiting plans/sketch, emergency telephone numbers, and personal rights are posted on the entry way wall. FILES: Resident and staff records are stored in staff room 1/Office. LAUNDRY : The laundry area is located in the laundry room (across from the main bathroom) which is accessible to residents in care. EXTERIOR : The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the backyard with benches for resident use. There are no bodies of water noted on the premises. The facility has an attached garage used storage. There are no other structures on the property. INFECTION CONTROL: The facility has an adequate supply of PPE and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. Facility is not in compliance with Title 22 Regulations at this time. Applicant will be required to complete the following corrections and submit documentation to LPA Jenny Olson within 10 days: - Video of water temperature measuring between 105-120 degrees Fahrenheit. Upon receipt of the above items, the physical plant will be in compliance with Title 22 regulations. This report will be sent to the Centralized Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. The applicant is aware that they are unable to operate under the new license number until they have been notified that the license has been approved by the CAB Analyst. Failure to comply could affect approval of the license. Exit interview conducted, copy of report printed.