Pre-licensing visit·December 22, 2021

Licensing Program Analysts (LPAs) Victoria Willis and Caitlynn Felias arrived announced to conduct a Pre-Licensing Inspection and met with Applicant, Arthur Alcones. Upon arrival, LPAs were screened for Covid-19 symptoms and had their temperatures checked. Facility is a one story residence with four client bedrooms, two single rooms and two shared rooms, three bathrooms and common areas. Facility plans to eventually have a capacity of 14 and will submit a change of capacity at that time. Resident rooms are furnished with a bed, chair and bedside table. Two bedrooms do not have a lamp and three bedrooms do not have dressers. Bathroom showers have bath mats and grab bars. Water temperature in bathroom read at 122 degrees F which is over the regulation of 105 & 120 degrees F. Facility has sufficient items used for cooking and eating. Facility has a locked pantry in the kitchen that may be used for centrally stored medications and files. Cleaning supplies and other items, like knives, will also be locked in pantry. Perishable and non-perishable foods observed per regulation. Facility backyard has an area for visiting and activities. Facility does not currently have a fence around the entire perimeter of the yard. At this time, facility is choosing to not admit residents with wandering behavior. Applicant has agreed to update their Plan of Operation to remove language regarding advertising for dementia and add policy regarding not admitting or retaining residents with wandering behavior. Facility received an approved fire clearance dated October 26, 2021 that allows for 4 non-ambulatory clients and 2 bedridden. Hardwired smoke alarms and Carbon Monoxide detector were tested and operational. Facility has emergency lighting in hallways. LPAs confirmed that contents of the facility First Aid Kit were sufficient. Continued on LIC809C Continued from LIC809 LPAs confirmed that Applicant is familiar with Guardian and has read the most recent Provider Information Notices (PINs) that the department sent out regarding Covid-19 vaccinations and visitation. Component III is waived due to Applicant being a current Licensee. The following items are needed in order to move forward with licensure: Noted updates to Plan of Operation Applicant to turn down water heater and submit three days of temperatures within regulation to LPAs Receipt showing that Applicant has obtained copies of Rights to Resident Councils and Family Councils for posting Once above items are received, LPAs will notify Application Unit so application process may proceed.