Pre-licensing visit·May 22, 2025

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a pre-licensing inspection and was greeted by caregiver. LPA contacted licensee Victoria Wainaina to advise LPA here to complete Pre-licensing inspection. Facility Administrator, Kennedy Wainaina arrived later. Facility currently has four [4] residents in care. LPA reviewed staff roster. LPA and Admin transferred all current staff from facility Elsa's Home 496803960 to Elsa Care Home 496804279. At approximately 9:30am LPA toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. LPA observed within regulation emergency supply of non-perishable food. Garage stores two [2] overflow food refrigerators. Garage has locked metal cabinet that stores toxins and cleaning products. One locked drawer in kitchen is dedicated for sharp knives. Cleaning products under kitchen sink locked. Facility is a one story residence with seven [7] bedrooms, one of which is a dedicated staff room, rooms one [1] and two [2] have a jack and jill style shared bath and room six [6] has a private half bath. Facility has two full bathrooms, dining and living room common areas, and a front sitting area used primarily for facility office administration. All resident rooms are furnished per regulation with a bed, lamp, dresser, chair and bedside table. Facility has central air and a back up generator. Present in the dining room is a ring camera. LPA asked Admin if there was a resident notification signed and on file, disclosing the video camera. Admin will provide disclosure notification to LPA before license is issued. Continued on 809C... Continued from 809... Water temperatures read at: 105.2 F in kitchen, 108.3 F in main bath, and 107.5 in full bath next to rooms five and six, all of which are within regulation of 105 & 120 degrees F. Smoke and carbon monoxide detectors present and functioning, last serviced by vendor January 2025. Facility has fire extinguishers present and charged, last serviced 2/10/25. Emergency lighting lanterns present in living room. LPA observed all required postings and posters present. Facility is currently and actively replacing left hand side of perimeter fence. LPA spoke to construction team and inquired as to portion of fence in the very front portion of the right hand side of the facility. Construction person indicated that currently, it is not scheduled to be replaced. LPA discussed with Admin that this portion of the fence will also need to be replaced in addition to the portion of the fence currently being replaced. Construction person informed LPA that estimated completion date of the fence should be by this Saturday, May 24, 2025. LPA showed Admin what appeared to be dry rot on bottom portion of front deck and some loose boards. LPA advised Admin to keep an eye on the stability of the deck structure and to replace once stability is no longer secure. Admin agreed and will have deck replaced/repaired if/when structure becomes unstable. LPA reviewed facility sketch. Sketch found to be accurate and depicts location of water, gas, and electrical shut offs as well as location of smoke and carbon monoxide detectors. LPA reviewed staff and resident files. The following items to be corrected prior to LPA submission of facility's application for approval: Training for all staff to meet hours requirement per regulation HSC1569.625(b), all staff must complete an additional 4 hours of dementia training with the following exceptions: S3 needs to complete annual continuation of training in the amount of 20 hours per HSC1569.625(b)(2) and S4 must complete 15 hours of training, six of which must be on dementia care. Additionally, S1, S2, and S4 need current 1st Aid/CPR and S1 needs a Health Screen (TB clearance is present and on file). Continued on 809C(2)... Continued from 809C... The following items to be corrected prior to LPA submission of facility's application for approval: Repair two loose boards on right hand side of backyard fence Screen to sliding glass door torn and cut in multiple places Street-facing front right hand side portion of fence to be replaced Signed resident notification of disclosure of camera in living room All staff must complete an additional 4 hours of dementia training with the following exceptions: S3 needs to complete annual continuation of training in the amount of 20 hours per HSC1569.625(b)(2) and S4 must complete 15 hours of training, six of which must be on dementia care. S1, S2, and S4 need current 1st Aid/CPR S1 needs a Health Screen (TB clearance is present and on file). Administrator to provide photos and/or videos of repaired/replaced items. Once acceptable photographic and/or video proof of corrections is received by CCL, LPA will submit facility's application for approval. Comp III reviewed and exit interview conducted with Administrator and a copy of this report given.